Coroners, inquests and medical negligence claims

It will surprise most people that there has been a coroner since about the 12th century.

The function of the coroner is to make inquiries into the cause of certain deaths – see below.

A coroner will be a barrister, solicitor, or registered medical practitioner, of no less than 5 years standing but ordinarily considerably more.

The office of coroner is an independent one i.e. it is quite separate and distinct from any judicial process, albeit coronial decisions are susceptible to legal challenge.

The coroner’s mission is a fact finding one, not a fault finding one.

The coroner does not determine blame for a death, or award compensation, for example, merely establishes its cause.

However, the issues and evidence provided in the course of the coroner’s investigation will often inform a subsequent civil case or criminal process.

Most coroners are assisted by several coroners’ officers, who are responsible for the day to day enquiries at the coroner’s behest to enable him/her to draw his conclusions upon the particular investigation.

In practice the coroners’ officers are likely to be former police officers who are experienced investigators and without whom the system would simply grind to a halt.

Members of the public will usually communicate with and through the officers, who will ultimately arrange the Inquest proceedings, where appropriate.

The Coroner’s jurisdiction is to inquire into violent or unnatural death, sudden deaths when the cause is unknown, and deaths in prison. Provided that the deceased person’s body is lying within his area, he may require an Inquest even if the death in question had occurred elsewhere, even outside England and Wales. Likewise, he may order for a body lying in his area to be exhumed.


An Inquest must be held when the coroner is informed that the body of a deceased person is lying within his jurisdiction and there is reasonable cause to suspect that the deceased:-

(a) has died a violent or unnatural death;
(b) has died a sudden death of which the cause is unknown, or
(c) has died in prison or in such a place or in such circumstances as to require an Inquest

An Inquest is, at its most basic level, an investigation by way of hearing involving the questioning of witnesses (under oath) for information or evidence as to the identity of the deceased, and how, when and where he/she came to die.

There are no sides or legal pleadings at all. No one is on Trial. Any questions allowed to be asked, whether by the coroner himself or by any of the interested persons present can and must only be directed towards and relevant to establishing the cause of the death.

Prior to the Inquest hearing the coroner’s officers will usually send to the interested parties, or their representatives, copies of the all the documents including witness statements.

Inquests are ordinarily held in public and are open to the press and the public to attend. The coroner will usually take a roll of those present.

The hearing will take place at a venue at the discretion of the coroner, such as a Magistrates Court, local authority meeting chamber or such like.

Questions of witness are asked first by the coroner and then by the interested parties. When all witnesses have completed their evidence, the coroner will hear any addresses from the interested parties on the law only, but not on the facts.

At the end of the Inquest, the coroner will give his verdict. This must not be expressed such as to impute any civil or criminal liability upon any person or body.

The coroner reaches his decision on the balance of probabilities i.e. more likely than not, except that he must be satisfied beyond reasonable doubt to bring a verdict of unlawful killing or suicide.

Although most readers will think of and be familiar with “natural causes”, ”neglect/lack of care”, “accidental death”, “unlawful killing”, “suicide”, it is common for the verdict to be given in a lengthier “narrative” format which allows it to be framed in more detail, and thus more specifically and appropriately for the individual case.

What can Lloyd Green, solicitors, do for you?

Attending an Inquest can be a distressing and intimidating experience and Lloyd Green, solicitors, will be happy to advise anyone who wishes to have more information about this or indeed to represent such a person at the hearing itself.

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