Why is a Coroner's inquest needed?

A Coroner will hold an inquest if, after preliminary investigations:

  • they're not satisfied about the cause of death
  • they're concerned that the death wasn't natural
  • the deceased was in detention (including detention under the Mental Health Act) at the time of their death.

The inquest process is a fact-finding, rather than fault-finding, process to help the Coroner establish the cause of death and the appropriate legal conclusion. There are no parties in an inquest, no indictment, no prosecution, no defence and no trial.

All interested parties (people entitled to take part and ask the witnesses questions) are entitled to be represented by lawyers at the inquest or any pre-inquest hearings. However, most inquests are conducted without any lawyers being involved.

The four questions the Coroner considers as part of their inquest are:

  • who the deceased was
  • where, when and how the death occurred.

How the death occurred is usually the focus of the inquest and means ‘by what means’ the death occurred. It isn't within the role of the Coroner to look into potential issues regarding matters of negligence.

At the end of the inquest the Coroner completes a ‘Record of Inquest’. This contains details about the deceased for the purposes of registering of the death.