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28 October 2015 0 Comments
Posted in Medical Negligence, Opinion

Inquests: Post mortem examination

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I have written previously about the circumstances in which a Coroner should open an Inquest following a death, and also the purpose of Pre-Inquest Review hearings. This blog considers the role of the post-mortem in the context of a Coroner’s inquiry.

What is a Pre-Inquest Review hearing?

I have written previously about the circumstances in which a Coroner should open an Inquest following a death.  A Pre-Inquest Review (PIR) is a hearing before the Coroner where plans are made for the inquest hearing itself. The PIR hearing is primarily for ‘housekeeping’ matters, with a view to ensuring that the inquest hearing runs as smoothly as possible.

In a complicated inquest there may be benefit in holding a number of Pre-Inquest Review hearings before the inquest takes place.

Pre-Inquest Review hearings were only formally recognised in July 2013 with the introduction of the Coroner’s (Inquest) Rules 2013.  Prior to this there was much inconsistency throughout England and Wales, with some Coroners holding PIR hearings frequently and others not at all.

Typical issues considered at a PIR include:

– Determining the list of ‘interested persons’;

– Proposing a list of witnesses, specifying who are anticipated to give evidence in person and whose statement might be read;

– The scope of the evidence and the issues to be considered;

– Whether a jury is required or, in circumstances where the Coroner can choose whether or not to have a jury, whether one is desirable;

– How long the hearing is likely to last and when it can be held;

– Whether there is a need for any expert opinion evidence’

– Whether an agreed bundle of documents will be used and, if so, who will prepare and paginate them;

– Other practical arrangements such as how video or audio material will be played, whether video conferencing is required for any witnesses who are abroad, or whether additional security is required or whether an interpreter is needed for any witnesses or interested persons.

Why is a Pre-Inquest Review helpful?

The rationale behind a Coroner holding a Pre-Inquest Review hearing is that it allows for more effective case management.  This ensures that the final inquest runs smoothly and with minimal delays, which is of vital importance, especially to the family of the deceased.  It also provides an opportunity to collate all relevant evidence, including conducting further investigations, in good time so that interested persons are able to consider the evidence fully.

The Chief Coroner, HHJ Thornton QC, was appointed to oversee the implementation of the new rules, which were intended to ensure greater consistency and to streamline the inquest process.  He has stressed the importance of Coroners considering whether a PIR would be of benefit. Whilst not generally necessary in inquests which are likely to be very short or which only deal with uncomplicated, uncontroversial deaths, the Chief Coroner recognised that a PIR can be of great assistance in saving time and cost down the line.  A lack of planning at the outset can lead to an inquest being adjourned, potentially after a wait of many months, for example where insufficient time has been allowed for the inquest hearing or where key witnesses had not been identified in sufficient time to enable them to attend and such adjournments and delays can be distressing for all those involved.

Best Practice Guidance

In the case of Brown v HM Coroner for Norfolk and Chief Constable of Norfolk (2014), the Chief Coroner set out the following guidance for Coroners to make the most of their entitlement to hold a PIR prior to an inquest:

– A Coroner should ensure that all interested persons have sufficient notice of the issues that are to be discussed at a PIR, generally with the use of a written agenda circulated in advance.

– The Coroner should ensure that interested persons have disclosure of any relevant statements/documents in advance of the hearing so that their content can inform submissions put forward at the PIR.  If documents are not available prior to the Pre-Inquest Review hearing then it can be agreed what steps ought to be taken and by when.

– The Chief Coroner has also stressed the importance of the Coroners not giving any impression of predetermining the conclusion of an inquest hearing and to appear impartial at all times. Whilst the Coroner may be familiar with those acting on behalf of a hospital or police constabulary in the local area they should take care not to appear too familiar.  HHJ Thornton QC reiterated that Coroners should only write letters or emails in the course of their work which would stand the test of looking unbiased and fair if read out during litigation.

If you are a family member of the deceased, do you attend the PIR?

If you have legal representation then your solicitor will attend the Pre-Inquest Review hearing to make submissions on your behalf.  Whilst it is not essential that the family of the deceased attend, my experience is that family members often find it helpful as an introduction to the Coroner’s Court in advance of the full inquest hearing.  It can be a useful opportunity to meet the Coroner, the Coroner’s Officer and to become familiar with the Court where the inquest will take place.

If you are unable to attend the PIR, or do not wish to, then your solicitor would take detailed instructions from you prior to the hearing and would speak to you after the hearing to discuss what happened.

If you have been advised that an Inquest will be held following the death of a loved one and would like further advice then please feel free to speak to an inquest solicitor.

If you wish to speak to a specialist lawyer about an inquest or about the circumstances of a death of a loved one then please get in touch with me or one of my colleagues.

01225 730 210     Email

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