Written by: Errol Archer

Is your organisation faced with an upcoming inquest? Have you been asked to provide a report to a coroner? Are you required to attend an inquest as a witness?

As a solicitor-advocate, I usually represent my clients personally at inquests rather than asking a barrister to do this. Having advised clients in relation to inquests and having attended inquests myself, I appreciate how intimidating and stressful the process can be for directors and staff. If any of the above questions apply to you or your organisation, please read on.

The purpose and nature of an inquest

The overriding purpose of an inquest is to answer the following four questions:

1. what the name of the individual is;
2. when they met their death;
3. where they me their death; and
4. how they met their death. In certain cases the coroner will also inquire as to “in what circumstances” they met their death.

It is not the role of an inquest to find fault with any individual or organisation or to attribute blame to any party. The coroner investigates, makes enquiries and questions witnesses at the hearing, with a view to answering the four questions.

It is important to keep in mind that an inquest is quite different from a criminal trial or a hearing in the county court, where there will be at least two sides trying to persuade the judge or jury to accept their point of view. In these courts, where there are opposing parties, the hearing is said to be adversarial. In contrast, inquests are inquisitorial in nature. The coroner is seeking answers to the four questions, instead of deciding which party has won the argument.

Consequently, a coroner will work to create an atmosphere in their court that is serious and respectful of the family of the deceased. Witnesses should therefore expect to find an atmosphere in the coroners’ court that is businesslike but not overly intimidating. 

Top tips

1. Allow sufficient time to prepare your statement carefully, answering any questions that the coroner’s clerk has asked ahead of the inquest hearing. Refer to relevant clinical notes and care records.

2. Ensure that you and your organisation respond in a timely manner to queries from the coroner or their clerks and remember that you should be seen to assist the coroner as much as possible.

3. Be open and transparent with the coroner and their staff at all times.

4. Arrive at the coroners’ court early to settle your nerves. Dress soberly, as if for an important business meeting.

5. If you are a witness, prepare for the hearing by re-reading your statement, looking back over care records and any relevant documents that the coroner has disclosed to you.

6. Be prepared for the family of the deceased to be at court. Remember to acknowledge them respectful, especially once you have been ‘sworn in’ in the witness box.

7. When giving evidence, if you do not know the answer to a question, say so and remember to direct your answers to the coroner or the jury.

Strategic considerations

As an owner of or leader in your organisation, it is important to be aware of the strategic considerations when preparing for and attending an inquest, for example:

• are there any steps that you should take to improve aspects of your service in light of the death?

• what action should you take in order to avoid the coroner issuing a ‘Report to Prevent Future Deaths’, which may damage your organisation’s reputation?

• should you be anticipating and preparing for a police or health and safety prosecution, following the inquest?

Further support and advice

If you would like further inquest support or advice please contact me.

Errol Archer Consultant Solicitor Advocate (Civil)