Editing Inquests in England and Wales

{{Short description|Judicial inquiry of unexplained deaths in England and Wales}}
{{Use dmy dates|date=March 2017}}
'''Inquests in England and Wales''' are held into sudden or unexplained deaths and also into the circumstances of and discovery of a certain class of valuable artefacts known as "[[treasure trove]]". In [[England and Wales]], [[inquest]]s are the responsibility of a [[coroner (England and Wales)|coroner]], who operates under the jurisdiction of the [[Coroners and Justice Act 2009]]. In some circumstances where an inquest cannot view or hear all the evidence, it may be suspended and a public inquiry held with the consent of the [[Home Secretary]].

==Where an inquest is needed==
There is a general duty upon every person to report a [[death]] to the coroner if an inquest is likely to be required. However, this duty is largely unenforceable in practice and the duty falls on the responsible [[Civil registration|registrar]]. The registrar must report a death where:<ref>''Halsbury'' vol.9(2) '''949'''–'''950'''</ref>
*The deceased was not attended by a [[physician|doctor]] during their last illness
*The death occurred within 24 hours of admission to a hospital
*The cause of death has not been certified by a doctor who saw the deceased after death or within the 14 days before death
*The cause of death is unknown
*The registrar believes that the cause of death was unnatural, caused by violence, [[neglect (English law)|neglect]] or [[abortion]] outside the exemptions of the [[Abortion Act 1967]], or occurred in suspicious circumstances
*Death occurred during [[surgery]] of any kind or while under [[anaesthetic]] both local and general
*The cause of death was or was suspected to be an [[industrial disease]]
*The death relates to public health or the general health or welfare of the public-at-large

The coroner must hold an inquest where the death is:<ref name="h939">''Halsbury'' vol. 9(2) '''939'''</ref>
*Violent or unnatural
*Sudden and of unknown cause
*In prison or police custody
*Suspected to be suicide

Where the cause of death is unknown, the coroner may order a [[post mortem]] examination in order to determine whether the death was violent. If the death is found to be non-violent, an inquest is unnecessary.<ref name="h939"/>

In 2004 in England and Wales, there were 514,000 deaths of which 225,500 were referred to the coroner. Of those, 115,800 resulted in post-mortem examinations and there were 28,300 inquests, 570 with a jury.<ref name="dca">{{harvp|Department for Constitutional Affairs|2006}}</ref> In 2014 the [[Royal College of Pathologists]] claimed that up to 10,000 deaths a year recorded as being from natural causes should have been investigated by inquests. They were particularly concerned about people whose death occurred as a result of medical errors. "We believe a medical examiner would have been alerted to [[Stafford Hospital scandal|what was going on in Mid-Staffordshire]] long before this long list of avoidable deaths reached the total it did," said Archie Prentice, the pathologists' president.<ref>{{cite news|title=10,000 deaths a year from natural causes 'need examining by coroners'|url=https://www.theguardian.com/society/2014/aug/27/pathologists-reforms-death-certificates-medical-examiners|access-date=27 August 2014|work=Guardian|date=27 August 2014}}</ref>

==Juries==
{{Main|Coroner's jury}}
A coroner must summon a [[jury (England and Wales)|jury]] for an inquest if the death was not a result of natural causes and occurred when the deceased was in state custody (for example in [[prison]], [[police]] custody, or whilst detained under the [[Mental Health Act 1983]]); or if it was the result of an act or omission of a police officer; or if it was a result of a notifiable accident, poisoning or disease.<ref>Coroners and Justice Act 2009, s.7(2)</ref> The senior coroner can also call a jury at his or her own discretion. This discretion has been heavily litigated in light of the [[Human Rights Act 1998]], which means that juries are required now in a broader range of situations than expressly required by statute.

==Scope of inquest==
The purpose of the inquest is to answer four questions:<ref>''Halsbury'' vol.9(2) '''988'''</ref><ref name="jamieson">''R v. HM Coroner for North Humberside and Scunthorpe, ex parte Jamieson'' [1995] QB 1 at 23, CA</ref><ref name=rules1984/>{{rp|r. 36}}
*Identity of the deceased
*Place of death
*Time of death
*How the deceased came by their death

[[Evidence (law)|Evidence]] must be solely for the purpose of answering these questions and no other evidence is admitted.<ref name="jamieson"/> It is not for the inquest to ascertain "how the deceased died" or "in what broad circumstances", but "how the deceased came by his death", a more limited question.<ref name="jamieson"/> Moreover, it is not the purpose of the inquest to determine, or appear to determine, [[criminal law|criminal]] or [[civil liability]], to apportion [[culpability|guilt]] or attribute blame.<ref name=rules1984/>{{rp|r. 42}} For example, where a prisoner [[hanging|hanged]] himself in a cell, he came by his death by hanging and it was not the role of the inquest to enquire into the broader circumstances such as the alleged [[neglect (English law)|neglect]] of the prison authorities that might have contributed to his state of mind or given him the opportunity.<ref name="jamieson"/> However, the inquest should set out as many of the facts as the public interest requires.<ref>''[http://www.bailii.org/ew/cases/EWCA/Civ/2003/1739.html R (on the application of Davies) v. Birmingham Deputy Coroner]'' [2003] EWCA (Civ) 1739, [2003] All ER (D) 40 (Dec)</ref>

Under the terms of article 2 of the [[European Convention of Human Rights]], governments are required to "establish a framework of laws, precautions, procedures and means of enforcement which will, to the greatest extent reasonably practicable, protect life". The [[European Court of Human Rights]] has interpreted this as mandating independent official investigation of any death where [[public servant]]s may be implicated. Since the [[Human Rights Act 1998]] came into force, in those cases alone, the inquest is now to consider the broader question "by what means and in what circumstances".<ref>''[https://publications.parliament.uk/pa/ld200304/ldjudgmt/jd040311/midd-1.htm R (on the application of Middleton) v. West Somerset Coroner]'' [2004] UKHL 10, [2004] 2 AC 182, [2004] 2 All ER 465</ref>

In disasters, such as the 1987 [[King's Cross fire]], a single inquest may be held into several deaths. Some inquests, such as the [[John Lawler inquest]], result in a [[prevention of future deaths report]].<ref>{{Cite web |date=November 26, 2022 |title=John Lawler: Prevention of Future Deaths Report |url=https://www.judiciary.uk/prevention-of-future-death-reports/john-lawler-prevention-of-future-deaths-report/ |website=[[Judiciary of England and Wales]]}}</ref><ref>{{Cite news |date=November 19, 2019 |title=Chiropractors Urged to Take X-rays First to Prevent Deaths |url=https://www.proquest.com/docview/2315371046 |work=[[The Daily Telegraph]] |page=9|id={{ProQuest|2315371046}} }}</ref>

==Procedure==
Inquests are governed by the {{not a typo|Coroners}} Rules.<ref name=rules1984>{{Cite legislation UK |type=si |year=1984 |number=552 |si=Coroners Rules 1984 |date=9 April 1984}}</ref><ref>{{Cite legislation UK |type=si |year=2004 |number=921 |si=Coroners (Amendment) Rules 2004 |date=25 March 2004}}</ref><ref>{{Cite legislation UK |type=si |year=2005 |number=420 |si=Coroners (Amendment) Rules 2005 |date=28 February 2005}}</ref> The coroner gives notice to near relatives, those entitled to examine [[witness]]es and those whose conduct is likely to be scrutinised.<ref>{{harvp|Mackay of Clashfern|2006|p=976}}</ref> Inquests are held in public except where there are real issues and substantial of [[national security]] but only the portions which relate to national security will be held behind closed doors.<ref name=rules1984/>{{rp|r. 17}}

Individuals with an interest in the proceedings, such as relatives of the deceased, individuals appearing as witnesses, and organisations or individuals who may face some responsibility in the death of the individual, may be represented by a legal professional be that a solicitor or barrister at the discretion of the coroner.<ref name=rules1984/>{{rp|r. 20}} Witnesses may be compelled to testify subject to the [[privilege against self-incrimination]].<ref name=rules1984/>{{rp|r. 22}}

If there are matters of national security or matters which relate to sensitive matters then under Schedule 1 of the Coroners and Justice Act 2009 an inquest may be suspended and replaced by a public inquiry under s.2 of the [[Inquiries Act 2005]]. This can only be ordered by the Home Secretary and must be announced to Parliament with the coroner in charge being informed and the next of kin being informed. The next of kin and coroner can appeal the decision of the Home Secretary.

==Verdict or conclusions==
The following conclusions (formerly called verdicts) are not mandatory but are strongly recommended:<ref>''Halsbury'' vol.9(2) '''1030'''</ref>
*'''Category 1'''
**[[Natural causes]]
**[[Industrial disease]]s
**Dependency on [[narcotics|drugs]] or non-dependent abuse of drugs
**Lack of attention at [[childbirth|birth]]
**Lack of care or self-neglect
*'''Category 2'''
**[[Suicide]]
**Attempted or self-induced [[abortion]]
**[[Accident]] or [[Death by misadventure|misadventure]]
**[[Capital punishment|Execution of sentence of death]]
**[[Lawful killing]] (formerly "justifiable homicide")
**[[Open verdict]] (cause of death unknown or unstated)
*'''Category 3''' – [[Unlawful killing]]
**[[Murder]]
**[[Manslaughter]]
**[[Infanticide]]
*'''Category 4'''
**[[Stillbirth]]

In 2004, 37% of inquests recorded an outcome of [[Death by misadventure|death by accident / misadventure]], 21% by natural causes, 13% suicide, 10% open verdicts, and 19% other outcomes.<ref name="dca"/>

Since 2004 it has been possible for the coroner to record a [[narrative verdict]], recording the circumstances of a death without apportioning blame or liability. Since 2009, other possible verdicts have included "alcohol/drug related death" and "[[road traffic collision]]".<ref name="cps.gov.uk">{{Cite web |title=Coroners {{!}} The Crown Prosecution Service |url=https://www.cps.gov.uk/legal-guidance/coroners |access-date=2023-04-27 |website=www.cps.gov.uk}}</ref> The civil [[standard of proof]], on the [[balance of probabilities]], is used for all conclusions.<ref name="cps.gov.uk"/> The standard of proof for suicide and unlawful killing changed in 2018 from beyond all reasonable doubt to the balance of probabilities following a case in the courts of appeal.<ref name="cps.gov.uk"/>

==Modernisation==
Owing in particular to the failures to notice the [[serial murder]] committed by [[Harold Shipman]], the [[Coroners and Justice Act 2009]] modernised the system with:
*Greater rights of bereaved people to contribute to coroners' investigations;
*A new office of [[Chief Coroner of England and Wales|chief coroner]] to lead and supervise practice;
*Full-time coroners with new district boundaries;
*Broader investigatory powers for coroners;
*Improved medical support for coroners' investigation and decision making;
*Vesting of treasure jurisdiction in the new office of treasure coroner with national responsibility.

== See also ==
*[[Committal procedure]]
*[[Fatal accident inquiry]], Scotland
*[[Immunity from prosecution]]
*[[Preliminary hearing]]
*[[Prevention of future deaths report]]

==References==
{{reflist}}

==External links==
*{{UK-LEG|title=Coroners Act 1988|path=ukpga/1988/13}}<br />This act extends to England and Wales only.
*{{UK SI|title=Coroners Rules 1984|year=1984|number=552}}

==Bibliography==
* {{cite web |last=Bishop |first=M. |year=2004 |title=Coroners' Law Resource |publisher=[[King's College London]] |access-date=2007-09-22 |url=http://kcl.ac.uk/depsta/law/research/coroners/index.html |archive-date=6 August 2007 |archive-url=https://web.archive.org/web/20070806090924/http://kcl.ac.uk/depsta/law/research/coroners/index.html |url-status=dead }}
* {{cite web |author=Department for Constitutional Affairs |author-link=Department for Constitutional Affairs |date=2006 |url=http://www.dca.gov.uk/corbur/reform_coroner_system.pdf |title= ''Coroners Service Reform Briefing Note'' |access-date= 21 September 2007 |archive-url= https://web.archive.org/web/20110525110158/http://www.dca.gov.uk/corbur/reform_coroner_system.pdf |archive-date= 25 May 2011 |url-status= dead }}&nbsp;{{small|(156&nbsp;KB)}}
* {{cite book | title=Coroners Courts: A Guide to Law and Practice | author=Dorries, C. | location=Oxford | publisher=Oxford University Press | year=2004 | edition=2nd | isbn=0-471-96721-1 }}
* {{cite web |publisher=[[Home Office]] |date=2003 |url= http://www.archive2.official-documents.co.uk/document/cm58/5831/5831.pdf |title=Death Certification and Investigation in England, Wales and Northern Ireland, The Report of a Fundamental Review 2003 |first1=Elizabeth |last1=Hodder |first2=Deirdre |last2=McAuley |first3=Anthony |last3=Heaton-Armstrong |first4=Colin |last4=Berry |first5=Iqbal |last5=Sacranie |first6=Tom |last6=Luce |url-status=dead |archive-url=https://web.archive.org/web/20070925185035/http://www.archive2.official-documents.co.uk/document/cm58/5831/5831.pdf |archive-date=25 September 2007 |df=dmy-all |id=[[Command paper|Cm 5831]]}}&nbsp;{{small|(1.17&nbsp;MB)}}
*&mdash; (2003b) {{cite web |url= http://www.rcgp.org.uk/pdf/ISS_SUMM03_08.pdf |title= ''Third Report into Death Certification and the Investigation of Deaths by Coroners'' |url-status= dead |archive-url= https://web.archive.org/web/20070925185034/http://www.rcgp.org.uk/pdf/ISS_SUMM03_08.pdf |archive-date= 25 September 2007 |df= dmy-all }}&nbsp;{{small|(191&nbsp;KB)}}, Cm 5854
*&mdash; (2004) {{cite web|url= http://www.archive2.official-documents.co.uk/document/cm61/6159/6159.pdf |title=''Position Paper Reforming the Coroner and Death Certification Service'' }}&nbsp;{{small|(382&nbsp;KB)}}, Cm 6159, {{ISBN|0-10-161592-2}}
* {{cite book |author=Levine |first=Montague |author-link=Montague Levine |title=Coroners' Courts |year=1999 |publisher=Sweet & Maxwell |isbn=0-7520-0607-X}}
* {{cite book |editor-last=Mackay of Clashfern |editor-first=James Peter Hymers |author-link=James Mackay, Baron Mackay of Clashfern |date=2006 |title=Halsbury's Laws of England |edition=4th reissue |volume=9 |chapter=Coroners |issue=2 |publisher=Butterworths |isbn=978-0-406-99946-7}}
* {{cite book |title=Jervis on Coroners |last=Matthews |first=P. |location=London |publisher=Sweet & Maxwell |edition=13th rev. |year=2007 |isbn=978-1-84703-114-3}}
* {{cite book |last1=Thomas |first1=T. |last2=Thomas |first2=C. |title=Inquests: A Practitioner's Guide |year=2002 |publisher=Legal Action Group |location=London |isbn=0-905099-97-4 }}

{{DEFAULTSORT:Inquest (England And Wales)}}
[[Category:Civil procedure]]
[[Category:Death in England]]
[[Category:Death in Wales]]
[[Category:Juries in the United Kingdom]]