Coroner and inquest process

Beverley Radcliffe is the Director of the Coroners’ Court Support Service (CCSS) . With her help, and by asking her about the most frequently asked questions we hear about inquests, we have put together this page of information, which we really hope is helpful.

We also recorded a podcast with her, which you might like to listen to.

The coroner and inquest process is quite long, and it might be confusing at times. If you would like any support, you can speak to the Coroner’s Court Support Service through their helpline number is 03100 111 21 41, Monday- Friday 9am- 7pm and Saturday 9am- 2pm. To learn more about the Coroners’ Court Support Service please visit their website.

Coroners and Coroner’s offices

Who is a coroner?

A coroner is an independent judicial officer. This means that they are like a judge, but they sit in a Coroner’s Court as opposed to a criminal court. They have certain legal obligations and there is a certain legal remit of the inquest process which they have to adhere to. Coroners before 2013 could be either a lawyer or a doctor, but if they were recruited after 2013, they now have to be a lawyer. This means they have to have experience in the law and they will sit independently. They are accountable only to the Lord Chancellor, so they can have a very independent, non-biased understanding and view of the inquest process.

How does the Coroner get involved after a suicide?

A death such as suicide will always be reported to the coroner. The coroner’s officer, on behalf of the coroner, will try and gain a better understanding of what happened to the person who took their own life. They will gather evidence and information to help them understand the circumstances leading to that suicide. They are required to start the process as soon as possible and this is known as ‘opening an inquest’. This is usually a brief meeting in the coroner’s court, allowing them to ‘adjourn’ (postpone) the full inquest to a later date to allow sufficient time for information to be gathered.

What happens next?

The coroner’s officer will contact the next of kin and explain to them what will happen next. There may then be some time between that first contact and the coroner’s office contacting them again, because in between that time the coroner’s office will investigate that death and speak to other people.

The coroner’s officer may speak to the police, witnesses, your family, and anyone else who may have information, or who spoke to the person in the last 24 hours of their life. They will also speak to the person’s GP.

All of this information will go into the coroner’s case file – or report – which they will bring to the inquest. They may use this file to call witnesses to the inquest, too.


The inquest process

What is an inquest? 

An inquest is a public court hearing to establish who has died, and how, when and where the death happened. A coroner must hold an inquest if it was not possible to find the cause of death from the post-mortem examination if the death is found to be sudden, occurred in prison, police custody or in hospital, or if the coroner thinks there are grounds for further investigation.

The inquest may be held with a jury, depending on the circumstances of the death. It is not a trial and its purpose is to discover the facts of the death, not to blame someone.

What is the inquest like? 

Most inquests are open to the public so other people, including the media, can be there.

When somebody walks through the door, either a volunteer or somebody at the reception will greet them and ask them who they are and which inquest they are there for. Then they will be taken to a quiet area so that they can sit there before the inquest starts.

When the time comes for the inquest, all the witnesses, the family members, and support people who are there will go into court at the same time. If there’s a volunteer present they will also go into court with you. Then witnesses are called to come to give their evidence and go through their statements, and the coroner will ask them questions relating to the statements.

Some inquests last for half an hour, some are a couple of hours, some may last a few days or even weeks – it just depends on the circumstances surrounding that person’s death. Most commonly, they do not last longer than a few hours.

After hearing the evidence, the coroner will make the ‘finding of fact’ (who the deceased was, when and where they died and the medical cause of their death) and the ‘conclusion’ (about how the person came by their death). This may be one of several conclusions and all have to be established ‘within the balance of probabilities’’. The most common are:

  • suicide’ (when the coroner is sure that the person intended to take their own life)
  • ‘open’ (when the cause of death cannot be confirmed and doubt remains as to how the death occurred)
  • ‘accidental or misadventure’ (where the person died as a result of actions by themselves or others that went wrong or had unintended consequences)
  • ‘narrative’ (when the coroner feels the other conclusions are not right for these circumstances and sets out his or her understanding of the facts)

The conclusion of the coroner can be difficult to accept or it can come as a shock. Some people, fully aware that the person took their own life, are confused when the conclusion is ‘open’ – it may make it harder to talk about what you believe happened. Others may be relieved to have an ‘open’ or ‘accidental’ conclusion. Some may find a conclusion of suicide distressing. A narrative conclusion may feel inconclusive.

Preparing for the day of the inquest

Wear whatever you feel comfortable in for the day. You do not have to dress formally, but you can if you would like it.

Remember to bring with you:

  • any documentation you have been given prior to the inquest
  • any questions you might have for the witnesses. If you are next of kin, you may be able to ask the witnesses questions when the coroner invites you to.
  • Pen and paper
  • Any medication, reading glasses, tissues, a soft drink and food if you wish
  • Your mobile phone to contact people if you would like to afterwards

Remember to give yourself plenty of time to arrive, and look at how to get there or where to park in advance. It can help to have a plan when you feel anxious

After the inquest

After the conclusion, the coroner will register the death and send the relevant paperwork to the registrar’s office. The next of kin can then ask for copies of the death certificate. It is often cheaper to order all the copies you need in one order.

Family and next of kin can ask for a recording of the inquest, from the coroner’s office.

Sometimes an inquest will show something could be done to prevent future deaths. If so, the coroner must write a report drawing this to the attention of the organisation or person that may have the power to take action. The organisation must respond within 56 days, stating what action it has taken. These reports are sent to the Chief Coroner and published electronically.


Some questions you may have

What happens if you don’t agree with that conclusion?

The conclusion is final – if you disagree with the conclusion, you can formally write to the coroner with reasons why. There are only very limited situations where you can disagree with the coroner and appeal that decision. You have to take it to a judicial review which is a lengthy and costly legal process. That shouldn’t put family members off but it’s definitely a consideration that families need to think about. There is detailed information in the Coroner’s Guide which can found on the Ministry of Justice website.

The media

This is one of the main reasons why people get anxious when they attend an inquest, particularly if the conclusion might be suicide. The inquest is public, so the media are allowed to attend, and report, on the proceeding and outcomes. You do not have to speak to the media at all, but you may wish to. You might want to appoint a member of your group attending to be the ‘spokesperson’. We have some information on the media, and how to work with them,

There are clear media guidelines issued by Samaritans about how to report appropriately on suicide, and you should complain if you feel these have been broken: in fact, Samaritans’ communication team can help you make the complaint and offer you support. You can also speak to the Independent Press Standards Organisation if you have been subject to intrusive enquiries or if you are concerned that coverage may affect other people’s safety.

Can I get the reports and evidence?

You can ask for a copy of the post-mortem investigation report and any other documents used during the investigation if you are next of kin or family. These reports are detailed and you may find them distressing. You may want to ask a friend or someone close to go through them in the first instance. For a fee, you can also ask for a recording of the inquest or a transcript of what was said.

Where can I find more information?

There are clear guides to the inquest process on, as well as information on how to register a complaint or lodge an appeal if you are unhappy with any aspect of the process.