Bereavement due to traumatic death

The coroner's inquest

A legal inquiry into a death is held when its cause is unknown, violent or ‘unnatural’. This 'coroner’s inquest' is held in public and the coroner determines the cause of death. He or she does not have to establish why the death occurred, but only who the deceased was, how, when and where death occurred. The verdict depends on many factors, including the post mortem examination. The coroner may have a meeting with the relatives before the inquest, but usually next-of-kin or other ‘interested persons’ meet the coroner’s officer.
The coroner’s officer, also known as the coroner’s investigator, works with the coroner, the bereaved relatives, the police, doctors and funeral directors and others. Some people told us that the coroner’s officer had been very helpful, and that she had prepared them very well for the inquest. Rachel, for example, recalled that the coroner’s officer had invited her to attend someone else’s inquest, so that she knew what to expect when it was time for her son’s inquest. However, others had been disappointed by the lack of information, and difficulties in obtaining documents. Most people met the coroner’s officer, but some only spoke to the officer by phone.
Pat, and her daughter Tamsin, explain what happened after Mathew died.
In the past relatives were not allowed to see witness statements or other evidence before the inquest, but it is now considered good practice for the coroner to supply relatives with witness statements and other evidence before the inquest. Since July 2013 rules from the Coroners and Justice Act 2009 came into force along with new coroner Rules and Regulations. The new provisions apply to all coroner investigations, including those which are already being investigated by a coroner or ones which may have already reached the inquest stage.The changes should mean that families are:
- more routinely informed of post mortems in advance;
- given an opportunity to give their views about non-invasive post mortems;
- be able to be present at post mortems and
- to receive (as soon as practicable) a copy of the report.

Relatives or other ‘interested persons’ used to have no right to look at documents and it was at the discretion of the coroner and some were charged a fee for copies of the post-mortem report and for copies of the coroner’s notes of evidence. David had to pay for a copy of a post-mortem report.
Some people do not want to see all the documents. After Rosemary’s son died in the London bombing in 2005 the coroner sent her and her husband the post-mortem report by post. She thinks a post-mortem report might upset some people and that it should not be sent without a request.
If anyone has been charged with a criminal offence the inquest will be opened and adjourned until after the criminal proceedings. At the opening of the inquest the coroner hears the facts that have been established about the death, and interim death certificates can be issued. When any trial is over the coroner will resume the inquest if he or she considers it necessary, but often the relevant facts will have come to light during the criminal trial and the inquest is not re-opened.
People often had to wait months or even years for the inquest, while the police were collecting evidence, or while suspected criminals were being tried in court. Some people told us they were still waiting for the full inquest years after the death.
Most people we talked to had attended the inquest, but a few had decided not to go because they did not want to hear more about how the death had occurred. Sometimes the inquest had been opened and adjourned very quickly and they had not realised it was taking place. Jocelyn’s son’s inquest took place in Hong Kong because he had been living there just before he died - Jocelyn did not attend.
Many found the inquest unexpectedly formal, rather like a High Court and some thought it frightening, austere and intimidating. William said that even his solicitor felt intimidated at the inquest when he discovered the school (in whose care William’s daughter was when she was killed) was being represented by a QC. The school, the coach company and the lorry driver’s company were all represented by barristers because they knew that the family might pursue a civil case against the parties who caused Lauren’s death. The coroner's verdict was ‘accidental death’.
During the inquest, relatives of those who died listened to evidence from people such as the police and the pathologist. Some relatives had to give evidence themselves. Others listened while the coroner read out their statement. Alison was upset and felt it was disrespectful when the coroner gave her daughter the wrong name. People were usually given an opportunity to ask questions, but some found that hard because journalists were there (also see ‘Media involvement’).
At the end of an inquest the coroner can give one of many verdicts, including death due to accident, suicide, or unlawful killing. A coroner may return an “open verdict” when he considers the evidence insufficient for any other verdict. A verdict can also be “narrative”, that is a more descriptive comment. In some circumstances, the coroner summons a jury to consider the facts and return the verdict. This happens if a death occurs in prison or other custody, or could have implications for health or safety in the future.

Once the verdict has been reached the coroner informs the Registrar of Deaths, who can then issue a death certificate.
Most people said that the coroner’s verdict was what they had expected, though some were disappointed that the inquest had not answered all their questions. A few were angry about the outcome. Dorothy had hoped that the Crown Prosecution Service would charge her son’s employer when Mark died in an industrial explosion in 2005. After many months investigating, the CPS decided against this, so in 2009 the coroner held a full inquest with a jury. Dorothy had hoped that the jury would return a verdict of unlawful killing but instead it gave a narrative verdict.
A coroner’s decision can be challenged by applying for a judicial review within three months. However, this is a complex process which needs a lawyer. A judicial review is a type of court proceeding in which a judge reviews the lawfulness of a decision or action made by a public body. In other words, judicial reviews challenge the way in which a decision has been made, not the rights and wrongs of the conclusion reached. If people want to challenge the coroner’s verdict a judicial review may not be the best way to proceed. People can at any time apply for a new inquest to be held, but it is better to apply as soon as possible and to get help from a solicitor.
Useful information about the whole inquest process can be found on a website run by an organisation called INQUEST. It provides independent free legal and practical advice to bereaved families and friends about the inquest process. It offers specialist advice to lawyers, bereaved people, advice agencies, policy makers, the media and the public on contentious deaths and their investigation.

Last reviewed May 2019.

Last updated May 2019.


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