Medical Negligence Inquest Solicitors

The coroner decides which witnesses attend and give evidence. If you are a “properly interested person”, such as a close family member, you can ask questions of witnesses yourself or instruct a lawyer to do so on your behalf.

Public funding is not generally available for inquest representation. It is limited to specific circumstances, such as deaths in custody or some cases involving mental health care. Where a later civil claim succeeds, the costs of inquest representation can often be recovered from the defendant.

Yes. Inquests are held in public and the press can attend, though it is a matter for individual journalists whether they choose to report on a particular case.

Burial or cremation can usually go ahead once the examination of the body is complete. An interim death certificate is issued while the inquest is ongoing, and the process can be delayed if there is a related criminal investigation or charge.

A coroner may only reach a conclusion involving neglect where the deceased was in a dependent position and the evidence shows a gross failure to provide basic care that is clearly connected to the death. It is a high bar, and specialist representation makes a real difference to how the evidence is tested.

Most inquests are held without a jury. A jury is convened for a smaller category of cases, including deaths in prison or state custody and some work-related deaths.

An Article 2, or “enhanced”, inquest applies where the state may have failed to protect the deceased from a known risk to life, or where they died in the state’s care, for example while detained under the Mental Health Act. It requires the coroner to examine the wider circumstances of the death, not just the immediate medical cause.

Where a coroner believes action should be taken to prevent similar deaths, they can write a Prevention of Future Deaths (or Regulation 28) report to the organisation best placed to act, most often an NHS trust.

es. A medical negligence claim is a separate process from the inquest, brought through the deceased’s executors or administrators. Evidence given at the inquest can support that claim, but the inquest itself does not decide civil liability.

Disclosure. NHS trusts and other healthcare providers frequently miss the deadlines the coroner sets for producing medical records and internal reports, which makes it harder for families to prepare and take part properly.

You are not required to have one, but an inquest lawyer can help identify the right questions, secure disclosure, and represent your interests at the hearing itself, particularly where the death may also give rise to a medical negligence claim.

Conclusions (verdicts) can be either short form or narrative conclusions. Short form conclusions relevant to the clinical context can include:

Short Form Conclusions Natural Causes: If the death occurred due to natural causes, the coroner can conclude that the deceased passed away from a medical condition without any external factors contributing significantly. Accidental Death: This conclusion is drawn when the death was unintentional and resulted from unforeseen events or accidents. Suicide: When the evidence indicates that the deceased took their own life, the coroner can conclude suicide. This conclusion requires careful consideration and sensitivity due to its profound impact on the deceased’s family. Unlawful Killing: If the death resulted from a criminal act, the coroner can conclude unlawful killing. This finding can lead to criminal investigations and legal proceedings. Open Conclusion: In cases where the evidence does not clearly support any of the above conclusions, the coroner may deliver an open conclusion, signifying that the circumstances surrounding the death remain unclear.

Additional possible verdicts of an inquest include:

Attempted/self-induced abortion. Accident/misadventure Industrial disease Want of attention at birth Dependence on drugs/non-dependent abuse of drugs

At the end of the hearing all the evidence the coroner will give the jury a summary of the evidence heard and will direct them as to the verdict they should return. The coroner may also give the jury the option of returning a narrative verdict in which the jury’s factual conclusions can be briefly summarised or he/she may invite the jury to answer factual questions.

In some circumstances, and in many cases in which we are instructed to represent families, the coroner may determine that a narrative conclusion is better than a short-form conclusion. A narrative will give the coroner (or jury) the opportunity to state what findings are made and what are not. Or alternatively, an open conclusion can have extra words appended by way of explanation.

Importantly though, coroners are encouraged to keep narrative conclusions short, and are strongly discouraged from including “expressions suggestive of civil liability, in particular ‘neglect’ or ‘carelessness’” (see R (Middleton) v West Somerset Coroner and another [2004]).

Family expectations

Families often have high expectations for inquests, often seeking detailed explanations and thorough investigations, which can often clash with the legal limitations which are placed on coroners by the statutory rules mentioned previously. It is important to be aware that a coroner’s inquest is an inquisitorial process and the scope of the inquest is under the control of the coroner. It is not an adversarial process, and whilst often people who were involved in, or responsible for, the Deceased’s care will give evidence, it is not a trial. The purpose of an inquest is not to establish liability or to impart blame on any given person or organisation.

Coroners and legal representatives must navigate the challenge of managing families’ expectations with empathy, ensuring that they are informed about the progress of the investigation, while respecting legal boundaries. Managing these expectations is an intricate process that requires clear communication and compassion.

The standard required for the coroner to reach a conclusion is the civil standard of proof (i.e. ‘on the balance of probabilites’) as opposed to the more burdensome criminal burden of proof (‘beyond reasonable doubt’).

Interestingly, until very recently if a coroner was to make a finding of suicide or unlawful killing, then they were required to apply the criminal standard of proof. However, this changed following the Supreme Court’s consideration and determination of these issues in the case of R (on the application of Maughan) v. Her Majesty’s Senior Coroner for Oxfordshire [2020] UKSC 46, in which the court held that the civil standard of proof applied to both suicide and unlawful killing. Whilst this arguably creates more certainty and consistency with the requirements for other conclusions, it has not been without its opponents.

On a more practical basis, there are other important considerations which should be borne in mind when preparing for and attending inquests.

There are a number of situations where a death should be reported to the coroner, such as where the deceased was not attended during his last illness by a medical practitioner, where the cause of death is unknown, or a death which appears to have occurred during an operation or before recovery from the effect of an anaesthetic.

Deaths are usually reported to the coroner by the police, by a doctor, or by the local register of deaths. The registrar should not register any deaths that have been reported to the coroner until the coroner finishes his enquiries. This means that there may be a delay before the funeral can take place (please see below).