Frequently asked Qs

• What are the key facts
  • If your relative dies in certain situations, a doctor will report their death to the coroner.
  • The coroner’s job is to find out who died, when, where and the cause of death.
  • The coroner will investigate the death. They may ask for a post-mortem examination or hold an inquest. 
  • An inquest is a public investigation. The coroner oversees it. An inquest will happen if they do not know how your relative died or if their death was unnatural.  
  • If your relative died in a psychiatric ward, prison or in police custody, there may need to be a wider, Article 2 inquest. 
  • Coroners should keep you involved. They should tell you about the inquest and post-mortem arrangements. 
  • If you are a parent, child, spouse or partner of someone who has died, you can register as an interested person. This means you can ask questions at the inquest. 
  • If the coroner holds an inquest, there may be a jury. 
  • At the end of the inquest, the coroner or jury will give a conclusion of how they think your relative died. 
  • You may disagree with a coroner’s decision. You can only challenge this through applying to the High Court.
• What happens after my relative has died?

  Doctors, the police, and registrars of births and deaths will report certain deaths to a coroner. 

  Deaths that are reported to a coroner include when: 

  • the cause of death is unknown,
  • the death was violent or unnatural,
  • a doctor has not been able to complete a death certificate, or
  • there are concerns about the cause of death.

  Anyone can report a death to a coroner if they are concerned about it. 

  Will the coroner investigate the death? 

  The coroner’s team will talk to relevant people to gather information about your relative’s death. For example, they may talk to your relative’s doctor. 

  Not all deaths which are investigated will need to have an inquest.

  You should be told if an inquest is needed.

  When will there not be an inquest?
  There will not normally be an inquest if the doctor confirms that the death happened because of: 

  • natural causes, or
  • a medical condition, and
  • there are no unusual circumstances. 

  If this happens: 

  • the coroner will issue a certificate to the deaths registrar which says neither a post-mortem nor inquest is needed, and
  • the death will be registered by the registrar. 

  In what circumstances will a death lead to an inquest?
  The coroner will carry out an inquest if they think that:

  • someone died a violent or unnatural death, 
  • the cause of death is unknown, or 
  • someone died in prison, police custody or state detention.

  State detention includes people:

  • detained in hospital under the Mental Health Act, and
  • in immigration detention centres.
• What is a coroner?

  A coroner is a judge appointed by the local authority (LA). But they do not work for the LA. This means that they are independent. 

  They investigate certain deaths that happen in their local area.

  A coroner is usually a legal professional. But sometimes they are doctors. 

  What does the coroner do? 

  The coroner must find out:

  • the identity of the person who has died,
  • how, when and where they died, and
  • any other details needed to register their death.

  The coroner will also use any information discovered during the inquest to help prevent other deaths where possible.

• What is a post-mortem examination?

  A post-mortem examination, or post-mortem, is a medical examination of your relative’s body. To find out the cause of their death. 

  Sometimes it is called an autopsy. 

  A post-mortem will happen as soon as possible following your relative’s death. 

  When a coroner arranges the post-mortem, this is carried out by an independent medical professional. Such as a pathologist. 

  A pathologist is a specialist doctor who can examine your relative’s body. They do this to find out how they died. 

  You can read more information on post-mortem examinations in a handbook produced by the charity, Inquest, here.

• What is an inquest?

  An inquest is an investigation into the facts of how your relative  died. 

  A coroner will look at different information and decide the cause of death.  

  The coroner will tell the next of kin, or the personal representative, when your relative’s inquest will take place.   

  There is usually a hearing to ‘open’ the inquest first. This is a short hearing. The coroner will usually then pause the inquest until a later date. This is so that they can get all the information needed to investigate the cause of death. 

  You can read more about what an inquest is in section 4 of a handbook produced by the charity, Inquest.

  What does an inquest cover?

  An inquest covers: 

  • who died,
  • how, when and where someone died,
  • information needed by the Births and Deaths Registration Act 1953, and,
  • anything that happened which breached the European Convention of Human Rights (ECHR). This will usually mean Article 2 of the ECHR, which is the right to life. 

  What is an Article 2 inquest?
  If there is any possible breach of human rights, the investigation must consider more events that might be relevant to their death.  This is called an Article 2 inquest. 

  An Article 2 inquest includes if your relative died while detained under the Mental Health Act. 
   
  You can read more information on deaths in particular circumstances, including Article 2 inquests, in section 5 of a handbook produced by the charity, Inquest, here.

• Why would I go to my relative’s inquest?

  The inquest can be a way of finding out about the events which may have led to your relative’s death. 

  Inquests are open to the public.  So, if you are not an interested person you can still go to the inquest. 

  Coroner’s offices have details of upcoming inquests on their website. If you cannot find it on their website, you can ring the office to find out.

• Will my relative’s funeral be delayed?

  If there is an inquest, it does not always mean that your relative’s funeral will be delayed. The coroner can: 

  • agree the funeral can go ahead, and 
  • issue a Certificate of the Fact of Death, known as an interim certificate.

  When the investigation or inquest is finished, the coroner will confirm the cause of death to the registrar. The registrar will register the death. Then you can ask the registrar for a death certificate.

• When and where will the inquest be?

  When will the inquest be held? 

  It varies. Inquests can be held a few weeks or a few years after the death. If there are complicated issues, and investigations involve many organisations, it can cause delays.

  You should be informed of the date of the inquest as soon as it is set. 

  You will be able to tell your solicitor, or the coroner, if there are any dates that would be difficult for you to attend. The coroner might take this into account. 

  If an inquest investigation takes longer than 12 months, it must be reported to the Chief Coroner.   

  Where will the inquest be held?

  Usually, the coroner where your relative died will do the investigation.

  If an investigation is transferred to a coroner in a different area, the new coroner will let you know. 

  The inquest could be held in a coroner’s court, a magistrates’ court or a room in the town hall. Sometimes a jury inquest may take place in a crown court. 

  In some circumstances, the coroner may decide a hearing is not necessary. And the inquest can be held in writing.

• What do I need to think about before the inquest?

  Can I get a copy of my relative’s health records?

  Being someone’s personal representative means you deal with their affairs after they have died. This includes dealing with their property, including their bank accounts. 

  If you are your relative’s personal representative, you can apply to see their medical records.  

  You can read more about being a representative here.

  These records may give you an idea of issues that might be relevant to the inquest. 

  You may find it difficult or upsetting to read through these records. If you have a solicitor helping you with the inquest, you could ask them to read the records for you. 

  For more information see our webpages on the following:

  • Access to health records
  • Confidentiality, information and your loved one

  What are pre-inquest reviews?

  The coroner may hold one or more pre-inquest review hearings. 

  At these hearings, the coroner and other interested people, decide about the practical arrangements for the inquest. This will include: 

  • setting a date for the inquest,
  • how long the inquest will take, 
  • which witnesses the coroner will need to call, and
  • how wide the investigation will be.

  You can go to these hearings if you want to. If you have a solicitor, they can go to these hearings for you. 

  Who can be a witness and how do they give evidence?

  Witnesses can be called to give evidence at the inquest. 

  The coroner decides who should give evidence.   

  They might request a report from an independent expert.  The coroner might need expert knowledge or assistance in understanding the circumstances surrounding a death.

  You can suggest witnesses to the coroner that you think could be helpful or important.  

  Evidence might be given orally or in writing.  

  Interested persons should be told who the evidence is from. And what has been said before the coroner reads it out. 

  Tell the coroner if you do not agree with the evidence. Or it being read out in court. The coroner will make a decision.  

  If you are asked to give evidence but think this will be too difficult, you can discuss it with the coroner’s office. If they agree, you have a right to give a written statement instead. This will be read out at the hearing. 

  How can I get a copy of the evidence before the inquest? 

  You will be given copies of documents that will be used in the inquest. This includes witness statements, medical reports and expert reports. 

  If you do not receive documents that you think you have a right to, speak to the coroner’s office.

  There may be documents that the coroner cannot give you for legal reasons. 

  The coroner should explain why they have not given you a document, or part of a document.

  Can I complain about my relative’s care or treatment?

  You may want to complain to an organisation about your relative’s care or treatment before they died. Such as the NHS or the police.

  Sometimes, an inquest can give you information that helps with a complaint. This is why many families wait until after an inquest to complain. 

  The NHS and police both have policies around time limits for making complaints.

  For more information see our webpages on the following:

  • Complaining about the NHS and social services 
  • Complaints about the police

  What if I think there has been clinical negligence?

  Clinical negligence is when healthcare professionals cause physical or mental harm to you because of the poor standard of care they give you.  

  If you think this happened to your relative see our webpage on Clinical negligence for more information.

• What are my rights at the inquest?

  You, or your representative, can ask witnesses relevant questions.  

  You can ask questions to help find out how your relative died, but you should not blame anyone. Only the coroner and jury decide what happened, based on facts, not opinions. Plan your questions ahead.

  You may want to get legal representation at the inquest to help you through the process. You can find more information on this in the next section below.

• What happens at the inquest?

  The coroner will start the inquest. 

  If there is a jury, the jurors take an oath. The coroner will explain to the jury that they are not there to blame anyone for your relative’s death.  

  The organisation, the Headlight Project, has made a 7-minute video to explain what happens at an inquest.

  Is there support available to me?

  The Coroners’ Court Support Service (CCSS) are a registered charity. 

  They can give you practical and emotional support while you are at the coroner’s court. 

  They are not available in every court. 

  There is more information in the Useful contacts section.

  What conclusions could be made?

  An inquest will end with a conclusion about how someone has died. Some of the conclusions are: 

  • accidental death or misadventure,
  • alcohol or drug related,
  • natural causes,
  • unlawful killing,
  • lawful killing,
  • suicide,
  • open, and 
  • narrative.

  What is an open conclusion?
  An open conclusion is when the coroner or jury does not have enough evidence to say how your relative died.  

  What is a narrative conclusion?
  A narrative conclusion is when a coroner or jury gives a longer explanation of what they feel are important issues. It can be a way of showing any problems or mistakes. For example, if there is an Article 2 inquest. 

  What about suicide verdicts?
  The coroner or jury no longer needs to have clear evidence to conclude that the death was the result of suicide. They can come to this conclusion if they feel it is more probable than not that your relative intended to kill themselves. 

  What is ‘contributed to by neglect’?
  You may feel that an organisation, such as a prison or hospital, neglected your relative. And were responsible for their death. In rare cases, the words ‘contributed to by neglect’ can be added to the conclusion. 

  Neglect does not mean the same in law as it does in everyday language.  So, there are not many situations when “contributed to by neglect" can be added to the conclusion.  

  What if future deaths could be prevented?  

  Sometimes an inquest will recommend changes to prevent future deaths from happening. 

  The coroner will write a report and recommend their changes to an organisation or person. For example, they might make recommendations to a hospital or psychiatric unit. This is called a ‘Prevention of Future Deaths Report.’

  The organisation must respond to the report within 56 days. They have to say what action they are going to take.

• Can I get legal help for the inquest?

  You usually must pay for legal advice and representation.  But you can get legal aid if:  

  • if it is an Article 2 inquest, or
  • if there is a wider public interest in the person being represented at the inquest.

  Legal aid in the above circumstances is not means tested.  This means that you can get legal aid for these reasons, regardless of your income or assets.

  If you do contact a solicitor, check that they have expertise in representing families at inquests. 

  The charity INQUEST may be able to recommend a solicitor to you. Their contact details are in the Useful contacts section.

  You might find the following 4-minute video useful called ‘Legal representation at an inquest’ by the Headlight Project.

• What happens after the inquest?

  How can I get a final death certificate?  

  After the inquest, the coroner will allow the death to be registered. The registrar will issue a final death certificate. 

  They will also send a burial order, a cremation certificate or permission to send the body abroad, if this has not already been done.

  Can I make a complaint?

  If appropriate, you can complain to a service about your relative’s care and treatment before their death.

  See the previous section for more information.

  What if I think there has been clinical negligence?

  If appropriate, you can make a claim for clinical negligence.

  See the previous section for more information.

  Should I tell the Care Quality Commission?

  If you have concerns about the standard of care your relative received in hospital, you could contact the Care Quality Commission (CQC).

  The CQC check that hospitals meet national standards.  It also checks that professionals are using the Mental Health Act properly.  

  The CQC will not investigate individual complaints. 

  You can share your experiences about hospital services on the Care Quality Commission website. 

  The CQC details are in the Useful contacts section.

  Can I contact a Member of Parliament (MP)?

  If appropriate, you could contact the MP for the area where your relative was getting mental health care.

  Many MPs are supportive and helpful if you raise these issues with them.

• Can I challenge a coroner’s decision?

  You can challenge a coroner’s decision or inquest conclusion. If you are thinking about doing this, speak to a specialist solicitor. 

  The only way you can challenge a coroner’s conclusion is:

  • apply to the High Court for a judicial review within 3 months, or
  • through the Attorney General to the High Court.

  How can I apply for a judicial review?

  If you want to apply for a judicial review this needs to be done within 3 months of the end of the inquest.

  You can challenge the decision this way if you think the coroner did not make a decision in a fair and legal way. It’s not about whether the decision was right or wrong. It about if the rules were followed. 

  When might I ask the Attorney General?

  You can ask the Attorney General to apply to the High Court for another investigation to be held. If this is in the interests of justice. For example, if new evidence has come to light. 

  There is no time limit for these applications.

• Can I make a complaint about a coroner?

  You can make a complaint if:

  • you are not happy with the way a coroner has behaved, or
  • you are not happy with the service provided by the coroner’s service.

  How do I make a complaint about a coroner’s behaviour?

  If you are not happy about a coroner’s personal conduct, you can write to the coroner.

  If you are not happy with the coroner’s response, you have a right to complain to the Judicial Conduct Investigations Office (JCIO). 

  If you do not want to complain directly to the coroner, you can also make the complaint to the JCIO. Their contact details are in the Useful contacts section.

  For more information see this Gov.UK link.

• Further reading

  The Ministry of Justice: A guide to coroner services for bereaved people
  This guide is intended for bereaved people and others who may be affected by a coroner investigation or are attending a coroner’s inquest.

  Website: www.gov.uk/government/publications/guide-to-coroner-services-and-coroner-investigations-a-short-guide

  INQUEST handbook
  This handbook is a resource for families and friends dealing with the aftermath of a sudden bereavement.

  Website: https://info.inquest.org.uk/handbook 

  INQUEST Skills and Support Toolkit
  This is a resource for families and friends dealing with the aftermath of a death in custody and detention.

  Website: https://info.inquest.org.uk/toolkit 

• Useful contacts

  INQUEST 
  A charity that provides advice and casework for bereaved people following a state-related death. They can also put you in touch with families who have been through similar experiences.

  Phone: 020 7263 1111, option 2
  Email: inquest@inquest.org.uk 
  Address: 3rd Floor, 89-93 Fonthill Road, London, N4 3JH
  Website: www.inquest.org.uk

  Care Quality Commission
  Monitors care in hospital and monitors the use of the Mental Health Act. 

  Phone: 03000 616161 
  Email: enquiries@cqc.org.uk
  Website: (webchat available) www.cqc.org.uk 

  Judicial Conduct Investigations Office (JCIO)
  Can take on complaints about the behaviour, language or conduct of a coroner. 

  Website: www.complaints.judicialconduct.gov.uk 

  Action against Medical Accidents (AvMA)
  Gives free, confidential advice and support to people affected by medical accidents, via a helpline and casework service. 

  Phone: 0345 123 2352 
  Website: (online contact form) www.avma.org.uk/help-advice/new-client-form/online-new-client-form/  

  The Coroners’ Court Support Service (CCSS)
  A registered charity whose volunteers give emotional and practical support to families and other witnesses attending inquests in certain parts of the country. 

  Phone:  0300 111 2141 
  Email: helpline@ccss.org.uk
  Website: www.coronerscourtssupportservice.org.uk

  Cruse Bereavement Care 
  Offers free, confidential help to bereaved people. Also provides counselling and support groups at local branches. You can find your local branch on their website. 

  Phone: 0808 808 1677 
  Website: www.cruse.org.uk 

  Compassionate Friends
  Support for bereaved parents, siblings, and grandparents.  

  Phone: 0345 123 2304 
  Email: helpline@tcf.org.uk
  Website: www.tcf.org.uk

  The Local Government Ombudsman (LGO)
  The final stage for complaints about a coroner’s service and local authority.

  Phone: 0300 061 0614 
  Email: you can fill in a complaint form through the website
  Website: www.lgo.org.uk

• Is this information accessible?
  • There is an accessibility function on this webpage called Recite.
  • On the desktop site, click on the icon in the top right-hand corner next to ‘Donate.’
  • On the mobile site, scroll right and click on the ‘Turn on accessibility’ icon.

  The Recite function allows you to:

  • translate the text into many different languages,
  • hear the text read aloud, in over 100 languages,
  • change the type and size of font, and
  • change the line height and character spacing,
    change the background colour of the text.

  You can watch a short video about Recite here.