1. Death Reported to the Coroner

The inquest process begins when a death is reported to the coroner. A death must be reported where the deceased's doctor is unable to issue a medical certificate of the cause of death, or where the circumstances suggest the death was violent, unnatural, or of unknown cause. Deaths may be reported by doctors, hospital staff, the police, prison officers, registrars of births and deaths, or any member of the public.

Not every death reported to a coroner leads to an inquest. The coroner will conduct a preliminary investigation to establish whether a full inquest is required. If the coroner is satisfied that the death was from natural causes and no further investigation is needed, the coroner may discontinue the investigation and allow the death to be registered.

2. Preliminary Investigation

Once a death has been reported, the coroner opens a preliminary investigation. This may involve obtaining medical records, speaking to the deceased's doctor, reviewing police reports, and gathering other relevant information. The coroner's officer (a member of the coroner's staff, often a former police officer) assists with this work.

At this stage, the coroner decides whether a post-mortem examination is necessary and whether the criteria for a full investigation (and therefore an inquest) under section 1(2) of the Coroners and Justice Act 2009 are met.

3. Post-Mortem Examination

The coroner has the power to order a post-mortem examination under section 14 of the Coroners and Justice Act 2009. A post-mortem is an internal medical examination of the body to determine the cause of death. It is conducted by a pathologist instructed by the coroner.

If the post-mortem establishes a natural cause of death and there are no other suspicious circumstances, the coroner may discontinue the investigation. The coroner will issue a notification to the registrar so the death can be registered, and the body will be released for burial or cremation.

If the cause of death remains unclear, or if the death was violent or unnatural, the investigation continues and an inquest will be held. In some cases, a special post-mortem (more detailed examination) or a second post-mortem may be commissioned, particularly in cases where criminal proceedings are anticipated.

4. Opening the Inquest

The inquest is formally opened at a brief hearing. The coroner records basic details: the identity of the deceased, the date and place of death (if known), and the fact that an investigation is underway. The opening hearing is often held soon after the death, primarily to allow the coroner to issue an interim certificate of the fact of death (which bereaved families need for practical purposes: notifying banks, insurers, and employers) and, where appropriate, to authorise the release of the body for burial or cremation.

The inquest is then adjourned to a date when the full hearing can take place. The adjournment may last weeks, months, or (in complex cases) over a year.

5. Pre-Inquest Review Hearing

In more complex cases, the coroner may hold one or more pre-inquest review (PIR) hearings. These are case management hearings at which the coroner and interested persons discuss the scope of the inquest, the witnesses to be called, the documents to be disclosed, and any legal issues that need to be resolved before the full hearing.

PIR hearings are particularly important in Article 2 inquests, where the scope of the inquiry may be wider and the volume of evidence greater. The coroner may give directions on disclosure, timetabling, the instruction of expert witnesses, and the format of the hearing.

6. Disclosure

Interested persons are entitled to receive disclosure of documents relevant to the inquest. The coroner decides what is disclosed, and the duty of disclosure is the coroner's, not that of any other party. Disclosure typically includes medical records, post-mortem reports, police statements, witness statements, investigation reports, and any relevant policies or procedures.

There is no automatic right to disclosure of all documents: the coroner must exercise judgement about what is relevant to the issues in the inquest. Interested persons may request specific documents, and the coroner will consider those requests.

7. The Inquest Hearing

The full inquest hearing is a public hearing (unless the coroner orders otherwise in exceptional circumstances). It is held before the coroner, or before the coroner and a jury where a jury is required or the coroner considers it desirable.

The coroner calls witnesses and examines them. Interested persons (or their legal representatives) may ask questions of witnesses, but only with the coroner's permission and subject to the coroner's control. Written evidence may be admitted where the coroner considers it appropriate.

The proceedings are inquisitorial: the coroner is in charge, not the parties. There is no cross-examination in the adversarial sense, though interested persons may challenge evidence and put their case to witnesses.

An inquest hearing may last a few hours (for a straightforward case) or several weeks (for complex cases involving multiple witnesses, expert evidence, and systemic issues).

8. Jury Inquests

A jury must be summoned for an inquest where (under s.7 of the Coroners and Justice Act 2009):

• The deceased died while in custody or otherwise in state detention
• The death resulted from an act or omission of a police officer or member of a service police force in the purported execution of their duty
• The death was caused by a notifiable accident, poisoning, or disease
• The senior coroner has reason to suspect that the death occurred in circumstances which are prejudicial to the health or safety of the public or a section of the public

The jury consists of between seven and eleven jurors. The jury decides the conclusion (the answers to the statutory questions of who, when, where, and how). The coroner directs the jury on the law and the available conclusions. A majority decision is acceptable, provided it is supported by at least five jurors where the jury consists of seven, or at least seven jurors where the jury is larger.

9. The Conclusion

At the end of the inquest, the coroner (or jury) records a conclusion. The conclusion answers the four statutory questions: who the deceased was, when they died, where they died, and how they came by their death.

The available short-form conclusions include natural causes, accident or misadventure, suicide, unlawful killing, lawful killing, industrial disease, drug-related death, alcohol-related death, road traffic collision, stillbirth, and open conclusion. A narrative conclusion may be recorded instead of (or in addition to) a short-form conclusion.

The conclusion is recorded on the Record of Inquest (Form 2), which is a public document. Certified copies are available from the coroner's office. The coroner must also send a copy of the Record of Inquest to the registrar of births and deaths so the death can be formally registered.

10. Prevention of Future Deaths Reports

One of the most significant powers of the coroner is the ability to issue a Prevention of Future Deaths (PFD) report. Under Regulation 28 of the Coroners (Investigations) Regulations 2013, the coroner has a duty to report to a person, organisation, local authority, or government department where the coroner believes that action should be taken to prevent future deaths.

The recipient of a PFD report must respond within 56 days, setting out the actions taken or proposed. Both the report and the response are sent to the Chief Coroner and are published on the judiciary website. PFD reports have led to significant changes in practice, policy, and legislation across a wide range of sectors, including healthcare, prisons, transport, and product safety.

PFD reports are not binding: they do not compel the recipient to take any specific action. However, a failure to respond, or an inadequate response, may attract public scrutiny and parliamentary attention.

11. Challenging the Outcome

There is no right of appeal from an inquest conclusion. However, an interested person may challenge the coroner's decision by way of judicial review in the High Court. Judicial review may be sought on grounds including that the coroner made an error of law, acted irrationally, or conducted the inquest in a procedurally unfair manner.

Alternatively, the Attorney General may apply to the High Court under section 13 of the Coroners Act 1988 (preserved by the Coroners and Justice Act 2009) for an order quashing an inquest and directing a fresh inquest, where it is necessary or desirable in the interests of justice.

12. Costs

The coroner's investigation and inquest are funded by the relevant local authority. There are no court fees for attending or participating in an inquest. However, the costs of legal representation for interested persons are their own responsibility.

As noted above, legal aid for inquests is extremely limited following LASPO. Exceptional case funding may be available in Article 2 inquests where the failure to provide legal aid would breach Convention rights. Bereaved families in non-Article 2 inquests generally face a choice between self-funding, finding pro bono assistance, or attending without legal representation.

Some organisations, including the charity INQUEST, provide specialist advice and support to bereaved families navigating the inquest system.

For more information on the legal framework, see our Key Legislation guide. For answers to common questions, see our FAQ.

This page is for general information only and does not constitute legal advice. If you have been bereaved and need advice about an inquest, please consult a solicitor experienced in coronial law.