The coronial inquest process explained

12 September 2025

7 min read

Police cars with flashing blue and red lights at night, creating colourful reflections and bokeh effects in the background.

When someone dies suddenly, unexpectedly or in circumstances that raise questions, the legal process that follows can feel overwhelming. One of the most important steps in understanding what happened is the inquest.

Inquests aren’t about blame — they’re about truth. They aim to give families answers and (where needed) ensure that lessons are learned to prevent future tragedies.

Whether you’re a family member, healthcare professional, employer or someone asked to give evidence, understanding the coronial process can help you to feel more prepared and supported.

Here, Thorrun Govind and Claire Burrows from our inquests team delve into how the process works.

What’s an inquest?

An inquest is a coroner-led legal investigation into a person’s death. It’s held when the cause of death is sudden, unknown, violent, occurs in custody or state detention or when there’s reason to believe that it may not have been due to natural causes. This may include cases that involve workplace accidents or medical treatments.

The coroner’s role is to answer four key questions:

Who was the person who died?
When did they die?
Where did they die?
How did they die?

An inquest isn’t a trial. There are no defendants and the inquest doesn’t assign blame or liability. It’s simply a fact-finding process — not an adversarial one.

An Article 2 inquest refers to an inquest held under Article 2 of the European Convention on Human Rights (ECHR), which protects the right to life. These inquests go beyond the standard scope and are required when the state or its agents may have been involved in the death or failed to protect life.

An inquest becomes an Article 2 inquest when:

The state (e.g., the Police, prison service, NHS, social services) may have caused or contributed to the death.
The state may have failed to take reasonable steps to prevent a death it knew or ought to have known was likely.
The death occurred in custody or detention and was violent, unnatural or unexplained.

The wider scope of an Article 2 inquest allows the coroner to examine not just “how” a person died, but “in what circumstances”, thereby allowing examination of systemic failings, policies and practices. This allows for greater scrutiny of the state and whether the state fulfilled its positive obligation to protect life.

What’s a coroner? What powers do they have?

Coroners are independent judicial officers who have legal or medical backgrounds. Though appointed by local authorities, they act independently of the Government, Police or other bodies.

Coroners have powers to:

Request medical records and expert opinions.
Summon witnesses and compel documents.
Issue fines or (in rare cases) imprisonment for non-compliance with their requests.

Their duty is to the public interest to ensure that deaths are properly investigated and risks to others are identified.

Understanding the coronial process

The coronial process begins when a death is reported to the coroner. This is typically done by a doctor, police officer or registrar. The coroner then decides whether a formal investigation is needed under the Coroners and Justice Act 2009.

The process begins with an initial review, where the coroner may order a post-mortem to determine the medical cause of death. Then, if the death is unnatural or unclear, a full investigation is opened.

In complex cases, a Pre-Inquest Review Hearing (PIR) may be held to set the scope, identify witnesses and plan the inquest hearing, where evidence is publicly presented.

Finally, the coroner will deliver a finding, known as a ‘conclusion’ as to the cause of death, that may be short form such as accidental death, natural causes or suicide, or a short factual narrative.

Before the inquest

Prior to an inquest, the coroner’s office will collect evidence to help determine its scope.

If you were involved in the person’s care or have relevant information pertaining to the inquest, you may be asked to provide a written statement. If your evidence is straightforward, it may be read into the record — meaning that you won’t need to attend the inquest hearing in person.

The coroner will also determine who is a properly interested person (also known as an interested person) for the purpose of the inquest.

Who is an interested person?

An interested person is someone who has a legal right to participate in an inquest under the Coroners and Justice Act 2009. Interested persons will always include the deceased’s family and may also include anyone who may have caused or contributed to the death, anyone whose actions or omissions are likely to be scrutinised, employers of the deceased, government departments or public bodies and anyone else that the coroner believes has a sufficient interest.

These individuals or organisations are entitled to receive disclosure of evidence, ask questions of witnesses (usually through legal representatives) and make submissions to the coroner about the scope of the inquest, the evidence required, which witnesses should be called to give live evidence during the hearing and what conclusions should properly be considered at the end of the inquest.

Will there be a jury?

A jury is required at an inquest in England and Wales in specific circumstances as set out in the Coroners and Justice Act 2009.

A coroner must summon a jury if the death falls into one of the following categories:

The death occurred in custody or state detention and was violent or unnatural or the cause of death is unknown.
The death resulted from an act or omission of a police officer or member of the armed forces in the execution of their duty.
The death was caused by a notifiable accident, poisoning or disease under health and safety legislation.

The coroner may also choose to summon a jury if there’s a reason to believe that the death was caused by a serious public safety failure, the case involves wider systemic issues that warrant public scrutiny or it’s in the public interest to have a jury.

The jury helps the coroner to determine the facts of the case (who, when, where and how the person died). Like the coroner, they’re not entitled to assign blame or liability.

Giving evidence at an inquest

If you’re asked to give oral evidence, you’ll do so under oath. Your duty is to the court — not your employer or any other party.

You’ll be questioned by the coroner and interested persons may also ask you questions.

Why inquests matter

Inquests are about understanding the past and protecting the future. If the coroner identifies a risk that could lead to future deaths, they must issue a Prevention of Future Deaths (PFD) report. This is sent to the relevant organisation to urge action to be taken.

While coroners can’t enforce changes, PFDs may lead to improvements in safety, training or policies.

It’s important to remember that while the coroner’s court doesn’t seek to determine criminal or civil liability, it’s an open court room where members of the public and press may be present — so any detailed examination of an organisation’s policies, procedures and decision making may need to be managed carefully to avoid negative PR.

It’s also common for families of the deceased to use the inquest process to obtain sufficient evidence to bring a civil claim against a relevant party after the inquest has concluded. Additionally, PFD reports and the requisite written response from the recipient are published online and available in the public domain.

Talk to us

Whether you’re a family member or a professional asked to give evidence, it’s normal to feel anxious or unsure.

Our experienced inquest lawyers are here to guide you throughout the inquest process. We’ve supported individuals and organisations across healthcare, education, social housing, local government and the private sector.

We can help you to: