Frequently asked questions

We would always recommend that you have legal representation where possible, especially if you have concerns about the circumstances of your loved one’s death.

Many families tell us that having a lawyer helped them to:

• Understand and navigate the inquest and any investigation processes;
• Liaise with the coroner about things such as upcoming hearing dates;
• Understand and manage disclosure (documents relevant to the inquest, such as medical notes);
• Obtain documents, such as investigation reports;- Make submissions and applications, and question witnesses in court;
• Feel that they were supported through the inquest process. It is also important to remember that other Interested Persons involved in the inquest, such as prisons, hospital trusts or police forces, will have their own lawyers (and sometimes several).

It is also important to remember that other Interested Persons involved in the inquest, such as prisons, hospital trusts or police forces, will have their own lawyers. 

Lawyers at inquests include solicitors, who give you advice and prepare for the inquest, and barristers, who represent you in court, for example by questioning witnesses. Some ‘solicitor-advocates’ are also qualified to represent you at inquest hearings. 

We always recommend finding a lawyer with specific inquest experience. It’s important that your lawyer has expertise in inquest preparation, gives you good advice, and understands how to help you get legal funding if this is available. 

INQUEST works with a network of lawyers across the country called the INQUEST Lawyers Group, who have specialist inquest experience. They usually only represent bereaved families at inquests, and not state bodies.  

If the circumstances of your loved one’s death fall within INQUEST’s casework remit, you may be able to find a solicitor by contacting us. Details of our remit and how to contact us can be found here.  

If you would prefer to find your own lawyer, you can use this website or see the useful contacts in our INQUEST Handbook. When contacting lawyers, ask them questions about their experience with inquests and the relevant investigation processes. We also suggest that you put your lawyer in touch with us, so we can provide them with additional advice, information and support. 

It is also sometimes possible to instruct a barrister directly to represent you at the inquest hearing, without first instructing a solicitor. This can be a useful option if you are not eligible for legal aid, or if you are having difficulty finding a solicitor. If you are considering this option, we suggest that you speak to an INQUEST caseworker first. 

Legal aid  

There are two types of public funding for an inquest. Legal Help pays for a lawyer to prepare for the inquest, and Exceptional Case Funding pays for a lawyer to represent you at inquest hearings. You might be eligible for Legal Help if: 

• You fall within the financial threshold set by the Legal Aid Agency. This requires an assessment of your income and is complicated to calculate. A lawyer should be able to advise you further. 

• If the inquest into your relative is an ‘Article 2 inquest’. Article 2 often applies where someone dies in the care or custody of the state (such as in prison, police custody, or when detained under the Mental Health Act 1983). In rare cases, Article 2 may also apply in other circumstances. If an inquest engages Article 2, then you should be eligible for legal aid without an assessment of your income. This is a complicated area of law, so speak to an INQUEST caseworker or your lawyer if you are unsure if your loved one’s inquest falls into this category. 

For more detailed information about legal aid, please see the INQUEST Handbook. For more information on Article 2, check the Handbook. 

Other ways to pay for lawyers 

Conditional Fee Arrangements/No Win, No Fee: If you are also pursuing a civil claim on your loved one’s behalf, some lawyers will cover the inquest costs through any compensation from a successful civil claim. This means you could be asked to pay if your civil claim is unsuccessful. Your lawyer should explain this very carefully. Make sure to get a second opinion or speak to an INQUEST caseworker if you have any doubts. 

Legal Expenses Insurance: Your home and motor insurance may cover the cost of inquest proceedings. However, this is very rare. You should check your policy very carefully to find out exactly what type of representation it might cover. If your loved one was a member of a trade union, the union may provide you with free legal representation at the inquest and help you in any claim for compensation.  

‘Pro bono’ help: Sometimes it is possible for us to find a lawyer who might be able to represent you for free. Your INQUEST caseworker will be able to tell you whether this might be possible. You can also apply for free legal representation from the charity Advocate. 

Crowdfunding: Crowdfunding using platforms such as CrowdJustice can sometimes be successful when traditional forms of funding representation aren’t available, such as when you would like to re-open an inquest but aren’t eligible for legal aid.  

Paying yourself: It is important to know that inquests can cost thousands of pounds, so you should think very carefully before deciding to pay privately. We would advise you to speak to your INQUEST caseworker first. 

Accessing medical records is not always straight forward. The law that governs records of people who died is called Access to Health Records Act (AHRA)1990. Under this legislation there is no automatic right to access records where someone has died. 

The first step you should consider is applying for probate (if the person who died had a will) or applying for a letter of administration if they died without a will. Once you have one of these then you don’t need to show any reason why you are seeking to access records as you will have an automatic right to receive them.  

If you don’t have probate or letter of administration, you can only apply for access where you can show that there is claim arising from the death. It is not enough to say that you are making general enquiries into the circumstances of the death or wish to make a complaint. Access can only be sought for the purposes of a claim such as the claim under Human Rights Act or clinical negligence claim.  

• From a GP: After someone dies, their GP records are sent to Primary Care Support England. To request these records, write to the Practice Manager of the relevant GP surgery. It can be helpful to tell them why you are asking for the records, for example that you might have a civil claim. 

• From an NHS hospital: You can apply to the ‘Access to Medical Records Team’ at the relevant hospital.  

• From a NHS Trust Investigator: If your relative’s death is being investigated by the NHS Trust, you can contact the investigator directly and asking for copies of records they have considered as part of their investigation.  

• From the coroner: You can also request the relevant medical records via the coroner, explaining why you think they will be relevant to the inquest.   

You have the right to be informed when the post-mortem examination is taking place and the right to have a representative present. You can notify the Coroner that you wish to have a representative present, only then will the Coroner notify you of the planned date, time and place of the examination. 

You are not entitled to personally be present but you can have a legal representative present. 

You also have the right to a second post-mortem and can ask the coroner to preserve your loved one's body while you consider this. Please see page 26 of INQUEST's handbook which deals with this point in more detail.

In order to have a second post-mortem, you will need to instruct solicitors who in turn will instruct a pathologist. There may be additional costs involved.

When the examination has been completed you can request the post-mortem report from the Coroner if they haven’t already provided it. However, it is quite normal for the first draft of the report to be delayed whilst they wait for the toxicology report. 

Primary Care

When someone dies their GP records will be passed on to the Primary Care Support England to be stored. 

To request them you should write to the Practice Manager of your relative’s surgery. The Practice Manager will be able to tell you where they are stored.

To request NHS hospital records, you can apply to the Access to Medical Records Team at the Hospital which your relative attended.

If the records were updated during the 40 days before the date of your application, you should be given access within 21 days. Otherwise the time limit is 40 days. 

Some people experience difficulties in trying to access their loved one's medical records and it can sometimes be complicated. If you have approached the primary care provider, it may be helpful to tell them the reason why you are asking for the medical records, particularly if is because you might have a civil claim arising from your loved ones death.

Trust Investigator

If your relative’s death is investigated by the trust, you can also contact the investigator directly and asking for copies of records they have considered as part of their investigation. 

The coroner

Another alternative is to try is to request the relevant medical records via the Coroner, explaining why you think they will be relevant to the inquest.

What is a Serious incident Report?

The NHS trust who was responsible for your loved one’s care might undertake an investigation into the events surrounding your loved one’s death. This is often called a 'Serious Incident Review' or a 'Root Cause Analysis investigation report'.

The purpose of the investigation

The purpose of these investigations is to establish the originating (or ‘root’) causes which are likely to have led to a death. The focus of the investigation will be on establishing any causes and contributory factors to a death, and identifying what lessons can be learned from them. The Trust's report should address:

• Establishing what happened
• Looking at the standards of care and whether there are any concerns in the standard of treatment or care received
• Addressing the family's concerns about care and treatment

It is worth noting that often the investigations are often not independent as they are carried out by the same Trust who provided care to your loved one.

You can bring a complaint within 12 months of your loved one’s death. This needs to be done in writing to the Chief Executive of the Trust. You can find out the details of the Chief Executive from the trust’s own website.

To do this, set out the issues you want to complain about in one or two pages. The Trust will then be obliged to investigate your complaint and tell you about their findings.

It would be helpful to copy the Coroner into the complaint so that he or she is also aware of the issues you have raised with the trust.

I have been contacted by the trust investigator and asked to meet with them. Do I need to go?

You may sometimes be called to meet with the Trust to set out your concerns. You do not have to meet with them if you prefer not to.

You could also ask for the information in writing first and then meet them, or you can wait until they have finished their investigation. However, sometimes these meetings can be helpful to find out some details of what happened directly from the care providers at an early stage, rather than waiting for the inquest and investigations to complete.

It would be helpful if you can find out the following:

• Details of who will be conducting the investigation:
• • their names;
  • their background;
  • their role in the Trust;
  • whether there is any degree of independence (ie. what connection they have with the service etc.); and
  • their experience/expertise in conducting investigations.
    What the 'terms of reference' for the investigation will be. This sets the scope and areas to be covered by the investigation.
    
    
• What the trust knows about the circumstances so far. It is usually best to ask for this in writing.
  
  
• The trust’s timeframe for conducting the investigation, and whether you will receive a draft of the report before it is finalised.
  
  
• Who you should contact for questions and information sharing through the investigation process.
  
  
• How and when they intend to keep you updated.
  
  
• Confirmation that they will fully disclose to you all relevant records and documents i.e. all evidence they will use to write the final report.
  
  
• You may also want to ask them about their internal processes for organisational responses and learning. How do they approach learning lessons? How does learning get shared? At what stages does this happen?

Other things to consider

You may also want to share any information you think may be relevant, and to raise any questions and concerns you have. You should be given more opportunities to feed into the process once you receive more information, but unfortunately this does not always happen as it should.

It may be worth asking if a face to face meeting is possible. This can help overcome the tendencies towards a more remote, paper-based approach. 

Lastly, always try to bring a friend or someone who can take notes, as these meetings can be really emotional. You can also ask if you can record the meeting. The investigators will be used to such requests and will often agree to this.

Families want to understand exactly what happened to their loved one and how they died. You might have questions which are unique to you and the circumstances.  

Here are some general questions you may wish to ask to help you to understand the circumstances of your loved ones’ death: 

• When did my loved one die?
• How did they die?
• Who was with them when they died/who found them?
• Was the death unexpected/unexplained? Could the death have been prevented?
• Were there any actions anyone could have taken, or would have been expected to have taken, to prevent their death?

If you do not feel able to meet the investigators face to face, you can either keep the communication strictly to emails and letters, or you can refuse to meet them, especially if you're planning to seek legal representation.

It is not unusual for families to reject meetings with trust investigators, as it is difficult to sometimes face representatives from the trust, who you might be holding responsible for your loved ones death.

You should not feel under any obligation to meet them, but please bear in mind that sometimes these investigation meetings can be helpful as they can give us some information about the circumstances, and their initial findings, which you may not be able to get otherwise.

Families want to understand exactly what happened to their loved one and how they died. You might have questions which are unique to you and the circumstances.  

Here are some general questions you may wish to ask to help you to understand the circumstances of your loved ones’ death: 

• When did my loved one die?
• How did they die?
• Who was with them when they died/who found them?
• Was the death unexpected/unexplained? Could the death have been prevented?
• Were there any actions anyone could have taken, or would have been expected to have taken, to prevent their death?

If you do not feel able to meet the investigators face to face, you can either keep the communication strictly to emails and letters, or you can refuse to meet them, especially if you're planning to seek legal representation.

It is not unusual for families to reject meetings with trust investigators, as it is difficult to sometimes face representatives from the trust, who you might be holding responsible for your loved ones death.

You should not feel under any obligation to meet them, but please bear in mind that sometimes these investigation meetings can be helpful as they can give us some information about the circumstances, and their initial findings, which you may not be able to get otherwise.

You have the right to raise issues which you believe are relevant to your loved one’s death to the coroner or Coroner's Officer. If you haven't been told who the Coroner's Officer is, you can call the coroner's court and request this information.  
 
You also have the right to write to the coroner outlining your concerns around your loved one’s care and treatment as early as possible. For more information, see our factsheet on drafting a witness statement here. 
 
This will help the coroner address all the issues from you and your family’s perspective. 

You have the right to ask the coroner for full disclosure of the relevant documents they hold. You can also request evidence that you feel is relevant but that the coroner hasn’t already asked for. It may be helpful to create a list of potentially relevant evidence from all possible sources, which you can send to the Coroner’s Officer so they can request the evidence you identified.  

You should also be sent the final ‘inquest bundle’ before the inquest starts. This contains all the relevant documents and evidence that will be considered during the inquest. 
 
Once you have received the evidence, you can go through it in order to narrow down or identify the relevant issues. You can also contact the charity Advocate, who offer to review documents in preparation for the inquest. 

It can be upsetting to read through evidence relating to a loved one's death. If you have requested evidence from the coroner, please be prepared to receive distressing material such as statements from those who had contact with your loved one before they died or from those involved in their care or treatment. 
 
If you received the evidence very late and don’t have time to read through it, you can request an adjournment. For more information, see our factsheet on adjournments here. 

As a relative of somebody who has died, you may be asked by the coroner to provide a witness statement. The purpose of a witness statement is to establish the factual background that led to someone’s death, information about that person’s care and any concerns that you may have. Even if you have not been asked, you may want to give a statement so that the coroner is aware of the concerns you have and questions you want answered at the inquest.  

Your statement can cover whatever information you think the coroner should know when making their investigations into how your loved one died. However, it can be very helpful for the coroner to know: 

1. Who you are and how you are related to the person who has died 
2. Who your loved one who died is. This can include a paragraph about who they were, what their family was like, their personality, and their hobbies 
3. What you know or remember about how they died. It can be helpful to write this in chronological order. If you got information from someone else, make this clear (e.g. “I was told by X that...”) 
4. What your concerns are. This can be your questions about how someone died, or concerns about how they were treated before they died 
5. Statement of Truth. You should end your statement by saying something along the lines of “this statement is true to the best of my knowledge and belief”. You should also sign and date your statement. 

During the inquest hearing, you can read the statement out yourself, or you can ask your lawyer or the coroner to read it for you. 

In many cases a family member will wish to read out a statement rather than have a lawyer do so but some families will find this difficult and ask their lawyer or the coroner to do it for them.

A pen portrait is a verbal or video statement about your loved one who has died. It will help the coroner (and jury, if there is one) to know more about your loved one – what they did, their interests and hobbies, details of their circle of family and friends, and what they meant to you.  

If you would like to do a pen portrait, you should talk to your lawyer about this or ask the coroner as early as possible. You can also take a photo of your loved one to the inquest and ask the coroner to show it.

Pen portraits can either be 

• Written and read out at the inquest. These are usually 1-2 pages long. 

• In video format, which includes images, videos and music. These are usually 2-5 minutes long. 

In some inquests, if you have written a statement then it is unlikely you will also need to write a pen portrait.  

In July 2021, the Chief Coroner published guidance on the use of pen portraits at inquests. You can also read more about pen portraits in the INQUEST Handbook. 

A pre-inquest review or hearing (PIR or PIRH) is an administrative hearing that is typically held where an inquest is complex or involves several Interested Persons. All Interested Persons or their legal representatives are usually present, and you are also allowed to attend these hearings. 
 
At the PIRH, the coroner will make decisions about the practical arrangements of the inquest. This includes decided who the Interested Persons are, whether it is an Article 2 inquest, whether a jury will be present, what disclosure is needed, which witnesses will attend the inquest, whether expert evidence is needed, and the dates of the final inquest hearing. The coroner will also decide the scope of the inquest during the PIRH. 

Before the PIRH, the coroner should tell you the time and date of the hearing and give you an agenda. This should let you know what will be discussed. If you haven’t received an agenda, the coroner should set out what will be discussed at the beginning of the PIRH. 
 
If you are going to the PIRH in-person, you can ask the coroner’s officer if you can arrive early and familiarise yourself with how the court room looks and where people will be sitting. If you are attending remotely, make sure you have received a link to join the hearing. This will usually be given to you by the coroner's officer. 
 
You can bring any notes you have made so far with you, including the questions or concerns you have given to the coroner, if you have a copy. 

For more information on PIRHs, see the INQUEST Handbook. 

Below is a general list of all the matters that will be considered or decided during a PIRH

Interested Persons

If this hasn’t been decided already, the coroner will note who all the interested persons are and identify any other potential interested persons.

Article 2 

The coroner should confirm whether Article 2 of the European Convention of Human Rights (the right to life) is engaged. They will also decide if a jury is required for the final inquest.

Jury

The coroner will decide if a jury is necessary for the final inquest. The function of the jury is to reach a finding of fact having heard all the evidence.

Scope of the inquest

The coroner should provide you with their initial view of any issues they have identified so far. This will be a starting point for how wide of a scope the inquest will have, what information they are considering and if they require further information from any of the interested persons, or other agencies which may be involved.

Disclosure

This is any evidence which the coroner receives which is relevant to the inquest. You are an interested person which gives you the right to have sight of disclosure. Some of it may have been shared with you in advance of the PIR. The coroner will also set deadlines for any outstanding documentation to be received by the coroner’s office. You can ask the coroner when you can expect disclosure to be shared with you if it hasn’t been already.

Witnesses

As with the scope of the inquest, the coroner will provide you with a provisional list of witnesses that they intend to call to give evidence in person and witnesses whose evidence will be read/ summarised by the coroner. If there is anyone that you would prefer to give evidence in person, make this known to the coroner. The coroner does have quite a wide discretion to decide on witnesses but there is no harm in making your views known.

Experts

The coroner may decide that an independent expert is needed to assist them with particular points of evidence. You can instruct an independent expert, but this is subject to funding. You can also make representations to the coroner if you think an independent expert is necessary. As with witnesses, the coroner has a wide discretion. If possible, ask for a copy of the letter of instruction, this is the letter which the coroner will send to the expert asking for their services and giving them terms of reference.

Dates and times

The coroner will establish when the final inquest hearing will be and/ or if any further pre-inquest reviews are necessary. They will note when it will be held, where it will be held (if a different location to the ordinary coroner’s court) and how long for.

You have the right to represent yourself or have someone advocate on your behalf at a Pre-Inquest Review Hearing (PIR) and/or Inquest.

Representing yourself should be the last resort, please ensure you have explored every avenue before making this decision.

If you have made the decision to represent yourself, you may wish to consider the following.

Please find a list of organisation who may be able to assist on the other sources of support page and download a copy of the INQUEST Handbook for more information on the law and your rights.

An inquest is a fact-finding hearing. The purpose is to answer four questions: 

1. Who died 
2. When they died 
3. Where they died 
4. How (and, sometimes, in what circumstances they died) 

An inquest is not like a criminal trial. It attempts to establish facts about what happened, rather than blaming someone for what happened. Inquests are overseen by coroners. 

Coroners decide who the witnesses and other Interested Persons will be, what evidence will be looked at and the scope of the investigation.  

The inquest will be attended by relevant witnesses, who will read their statement and can then be questioned by the coroner, you/your legal representative, other Interested Persons’ representatives, and (if there is one) the jury. 

After the coroner has heard from all the witnesses, they will ‘sum up’ the evidence. Then, the coroner (or the jury) will give their conclusion. Some possible conclusions include that someone died by: 

• Natural causes 
• Suicide, or taking own life whilst the balance of their mind was disturbed 
• Accident or misadventure 
• Lawful killing 
• Unlawful killing 
• Dependence or non-dependent abuse of drugs 
• Disaster 
• One of the above “contributed to by neglect” 
• Open conclusion (meaning doubt remains about how someone died) 

Sometimes, a narrative conclusion will be given. This means the coroner or jury give a longer explanation about what they think the important issues are. This will not name individuals as being at fault, but can expose significant problems or mistakes. 

For more information on what happens during an inquest, see the INQUEST Handbook. For more details on inquest conclusions, see the INQUEST Handbook. 

For practical tips on attending an inquest, see our Final Hearing Checklist, which was prepared by family members. 

We understand that the inquest process in itself can be difficult. Below is some information that might help you during the inquest, which has been put together with the help of families who have been in similar circumstances to yourself. Practical tips:

• Have a support network set up (including counselling/bereavement support or friends and family
• Keep a note pad to record questions as they arise
• Take sticky notes so you can pass questions to your solicitor/barrister
• Have tissues and water
• If you are attending the court in person, take a packed lunch and refreshments, as they are not always available nearby
• Arrive early and speak to the clerk about having a room which you can go to between sessions
• You can leave the court room at any point if you need to take a break
• Check travel arrangements including the route to court to avoid diversions and delays  

Remote Hearings (if not attending in person):

• Make sure you have a good internet connection, and your computer is fully charged
• Test your camera and microphone the day before you join to check it works
• Arrange a private line of communication with your lawyer, either by email or WhatsApp so that you can ask questions as they arise during the inquest
• Put your microphone/audio on mute during the inquest. This will mean that you don’t have to ‘leave’ and re-enter the inquest.  

Self-care:

• Prepare to hear information which may be distressing
• Pace yourself and take regular breaks away from the documents
• Be in nature 
• Do something different in the evenings to give you a break from the inquest process
• Write down how you feel, even if it is just expletives!
• Be aware that everyone grieves differently and will be at different stages within the family 
• Give each other space  

OTHER SOURCES OF SUPPORT

An ‘adjournment’ is when the Pre-Inquest Review Hearing or final inquest hearing is postponed until another date. This could be for several reasons, for example a witness not being available, or needing to pause the inquest pending further investigations.  
 
In some circumstances, you/your legal representative may want to write to the coroner to ask them to adjourn the inquest. It is up to the coroner whether or not to adjourn, and the coroner will also decide when to resume the inquest again.  

Generally, coroners prefer not to adjourn if possible, as they have a legal duty to consider how delays impact their duty to investigate how your loved one died. However, sometimes it is reasonable for the coroner to adjourn for the inquest to run properly. 

The coroner might decide themselves that an adjournment is necessary, or one of the Interested Persons in the inquest might request an adjournment.

There are several reasons why an inquest might be adjourned, such as:

• You haven’t had enough time to instruct lawyer and get legal advice;
• You haven’t had enough time to apply for legal aid funding;
• You haven’t yet received important disclosure (such as investigation reports, hospital records or CCTV);
• The coroner decides that they need to call certain witnesses or request an expert;
• The coroner decides that some further investigations or enquiries need to be carried out;
• You need to submit further written evidence and the coroner agrees it is necessary; or
• You want to make submissions to the coroner on the scope of the inquest. 

You can either ask your solicitor to make an application or, if you don’t have a solicitor, you can make an application yourself. Generally it is better to request an adjournment as soon as you realise it might be necessary. 

To request an adjournment yourself, you should put your request in writing directly to the Coroner. However, we would advise that you discuss this with your INQUEST caseworker first. Your caseworker will be able to advise you on the process, and may be able to help you draft the request.   

To write your request, we have provided a suggested template below:

• Address your letter to ‘HM Coroner [name]’ and begin with ‘Dear [Sir/Madam]’.
  
  
• Start by setting out why you are writing, for example: ‘I am writing to kindly request an adjournment of the [Pre-inquest Review Hearing] currently listed for [date of hearing].’
  
  
• Include a brief summary of what happened to your loved one.
  
  
• Clearly set out your reasons for requesting an adjournment. For example:
  
  
  • ‘We have reviewed the documents we have been provided with and we would like to seek specialist legal advice on the issues.’
  • ‘We have not yet received the [PPO report/SIR report/IOPC report/other relevant documentation] and we would like to review this before we can outline our concerns to the coroner.
    
    
• Thank the coroner and sign-off your letter, for example: ‘We sincerely hope you will agree that an adjournment is necessary in the circumstances. We are very grateful for giving this matter your attention. Thank you for your time and anticipated assistance.’

The coroner will consider your request for an adjournment and inform you whether they intend to adjourn. 

If the coroner decides that an adjournment is necessary, the coroner must inform the next of kin or personal representative of the deceased and any other Interested Persons:

• That the inquest has been adjourned;
• When the inquest was adjourned;
• Why the inquest has been adjourned; and
• When and where the inquest will resume again.

You have the right not to be excluded from all or part of the inquest if you are an Interested Party. 

Ensure that the you have the date, time and location of the inquest in order to attend. If the inquest is being held remotely, this will often be done via the platform 'Microsoft Teams' and you will be sent a link by the coroner's officer in order to attend online.

You have the right to question the witnesses, but please bear in mind that the coroner may limit the questions if they think the questions are not relevant.

When you receive the witness list and have reviewed the statements, write a list of questions you may want to ask of each witness. 

Note: if you do not want to ask the questions yourself, you can submit your questions prior to the inquest to the Coroner to ask on your behalf.

You can also pass questions to the Coroner during the inquest. If the inquest is being conducted remotely, ask the coroner at the start of the hearing how they would like you to do this.

Do

• Keep in contact with the Coroner’s Officer – they will provide you with all the practical information you require.

• Arrive on time – gives you a chance to get settled in and introduce yourself to the Coroner & Coroner’s Officer.

• Ask Questions – the Court knows you are not legally qualified; you are not expected to know everything. The Coroner is there to assist you.

• Dress formally.

Don't

• Put too much pressure on yourself – inquests can be extremely distressing.
• Bring children – children under the age of 18 are not permitted to attend the hearing or give evidence.
• Come alone – if you have the option to bring other family members/friends to the hearing to support you, then do so.
• Talk to the media during the inquest.

This is a checklist that was put together by family members we work with, to help other families attending an hearing. The important thing is to look after yourself before, during and after the hearings and the below includes some suggestions to minimise anxiety.

We do recognise that people deal and cope with the process in very different ways, so these are merely some suggestions that may or may not assist you.

Practical tips:

• Have a support network set up (including counselling/bereavement support or friends and family).
• Have some ‘easy dinners’ in the fridge or freezer (you may want to batch cook in advance or ask somebody else to cook). You will probably feel tired and drained when you get home.
• Keep a note pad to record questions as they arise.
• Take sticky notes so you can pass questions to your solicitor/barrister.
• Have tissues and water.
• If you are attending the court in person, take a packed lunch and refreshments, as the court's may operate reduced services due to coronavirus .
• Wear something smart but comfortable and bring a jumper as the courts can get cold.
• Decide on what you want to wear the night before and have it ready before you go to bed.
• You can leave the court room at any point if you need to take a break.
• Check travel arrangements including the route to court to avoid diversions and delays.

Remote Hearings:

• Make sure you have a good internet connection, and your computer is fully charged. 
• Test your camera and microphone the day before you join to check it works. 
• Put your microphone/audio on mute. This will mean that you don’t have to ‘leave’ and re-enter the inquest. 
• Have a line of communication with your lawyers so that you can pass on questions to them during the hearing. 

Self-care:

• Prepare to hear information which may be distressing. 
• Pace yourself and take regular breaks away from the documents. 
• Be in nature. 
• Do something different to give you a break from the inquest process. 
• Write down how you feel (even if it is just expletives). 
• Be aware that everyone grieves differently and people will be at different stages within the family. 
• Give each other space. 
• Talk to friends, whilst recognising that different friends will offer different levels of support and understanding. 
• Be honest with family and friends about how you feel. 

In reaching any conclusion, the Coroner has to be sure ‘on the balance of probabilities’ (or more likely than not) that this is how someone died.

A conclusion of suicide and unlawful killing used to be held by the criminal standard (beyond reasonable doubt) but this was changed to be ‘on the balance of probabilities’ in May 2019, following the case of Maughan.

N.B. The Maughan decision does not retroactively apply to inquest conclusions.

Once a Coroner or jury have heard and considered all the evidence at an inquest, they will give a conclusion as to how someone has died. There are different types of conclusions a Coroner or jury can give

All inquest conclusions are written down on a Record of Inquest.

A copy of this will either be given to you on the day the inquest concludes or sent to you soon after.

The Coroner will also send all the necessary information to the Registrar of deaths so that you can be given a finalised death certificate. You should be given information about how to get the Death certificate by the Coroner’s office.

The Coroner or jury may give a short form conclusion, which is a finding of one or two words, such as: 

• Natural causes
• Accident or Misadventure
• Unlawful or Lawful killing
• Alcohol or Drugs-related
• Suicide
• Industrial Disease
• Road Traffic Collision
• Open – meaning there is not enough evidence to decide how someone died. 

Where a short form conclusion is not enough, the coroner or jury will outline more descriptive factual findings in a narrative conclusion.

These can be anything from one or two sentences in length to a longer paragraph. Occasionally, if a jury is present, the coroner may draw up a questionnaire which captures the key points heard at the inquest to help them to reach a narrative conclusion.

If there is evidence of very serious failings, a coroner might combine a short form conclusion with the phrase ‘contributed to by neglect’, e.g. ‘natural causes, contributed to by neglect’. ‘Neglect’ has a very narrow meaning legally and is not used in the same way at an inquest as how it might be used ordinarily. If you are not sure about this, it is sensible to speak to your lawyer.

Someone may die by their own hand, but the inquest will not always be concluded as a suicide - there has to be factual evidence to show that the person intended to end their life.

If there is no evidence to show this, the Coroner may decide that a conclusion of Misadventure or Accidental Death, or leaving it Open, is more appropriate.

There is no right of appeal for inquest conclusions.

The only way to challenge them is by judicial review, which is a complex legal process in which a judge reviews the lawfulness of a decision or action made by a public body (e.g. The Coroner’s Court).

There is a very short amount of time after an inquest has concluded to judicially review the decision, it typically must be done within 3 months.

You should seek legal advice as soon as possible if you want to pursue a judicial review.

When a coroner is investigating a death, and that investigation reveals a concern that a risk of death will continue to exist in the future, then the coroner must report this to any person or body that has the power to take action to prevent future deaths. This is usually referred to as a Prevention of Future Deaths report, or PFD. 

After being sent a PFD, the relevant person or body has 56 days to send a written response. This must explain what action they are taking or will take or explain why no action is being taken. The PFD and any responses should be shared with all Interested Persons, including the family. 

However, the coroner’s recommendations cannot be enforced. This is why INQUEST is campaigning for the establishment of a National Oversight Mechanism. Such an independent body would collect PFDs, analyse responses, and follow up on progress and escalate concerns. Read more about our No More Deaths campaign. 

A post-mortem is a medical procedure that happens after someone has died. It is carried out by a doctor called a pathologist. It takes place where the cause of death is unnatural or unknown, and the purpose is to find out what caused the death. Usually, a post-mortem is conducted 24-48 hours after someone has died. 

You have the right to be informed when the post-mortem examination is taking place. You do not have the right to be personally present at the post-mortem, but you can have a representative present. To find out the planned date, time and place of the post-mortem, you need to tell the Coroner that you wish to have a representative present. You can do this by writing to the Coroner’s Officer. 

If it hasn’t already been shared, you can ask the coroner to send the post-mortem report to you after the examination has been completed. However, it is normal for the report to be delayed when waiting for a toxicology report, which can take 6-8 weeks. 

For more detailed information about post-mortems, please see the INQUEST Handbook.