Search our news, events & opinions

29 April 2019 0 Comments
Posted in Health & Social Care, Opinion

The inquest process – the basics for care providers

Author headshot image Posted by , Partner

Care is an inherently challenging area to work in. As a social care provider you may well become involved in inquest proceedings, following the death of a service user.

social care royds withy king

What is an inquest?

An inquest is an investigation led by a coroner, into the circumstances of a death. As part of this, the coroner must answer four questions:

  1. The name of the deceased.
  2. Where the deceased died.
  3. When the deceased died.
  4. How the deceased died.

Not all deaths require a coroner’s investigation. A coroner will hold an inquest in specific circumstances, such as when he/she believes that a person has died a violent or unnatural death, the cause of death is unknown or where the deceased died in custody or another state detention. There are also some inquests which are required by law, such as where the death is thought to result from industrial disease such as asbestosis.

For care providers this may include where a service user has died unexpectedly, or following a fall or a choking incident, for example.

What does the inquest process involve?

The inquest process is usually managed by the coroner local to where the death occurred. Different coroners often take a slightly different approach to the process. However, the main elements of the investigation will be:

  1. A post mortem will usually be undertaken by a pathologist to try and establish a medical cause of death. The pathologist’s post mortem report will usually be disclosed to those involved.
  2. A pre-inquest review hearing may be held. This is a hearing before the inquest where the coroner will meet with the relevant parties (‘Interested Parties’ in an inquest) and consider practical steps that need to be taken before the inquest. For example, what documents need to be disclosed and which witnesses will need to appear to give evidence. Please see our upcoming blog for more detail on how to prepare for a PIR.
  3. Documents and disclosure. The coroner will often request that statements are taken from key individuals who were present before or during the death. Other key documents that the coroner may request from care providers are risk assessments, care plans, medicine administration records or care records.
  4. The inquest hearing. The hearing itself may vary in length from just a few hours to many weeks. In certain circumstances it may be held with a jury, otherwise it will be held in front of the coroner. Witnesses will either be called to give ‘live’ evidence or their statements will be read out, depending on whether their evidence is disputed.

At the end of the inquest, the coroner will summarise the evidence heard, give a ‘Conclusion’ (previously known as a ‘verdict’) and complete the Record of Inquest. An inquest’s purpose is not to place blame on any organisation or body.

Conclusions can include natural causes, accidental death, neglect or suicide, amongst others. Sometimes a coroner will not give a ‘short form’ conclusion such as those listed above but will give a short factual passage stating what occurred prior to the death. If a jury is involved, it is them who will determine the conclusion following guidance given by the coroner.

In some circumstances the coroner will also prepare a ‘Regulation 28 report’ or ‘Prevention of Future Death Report’. This is a public report which the coroner sends to relevant organisations where he/she believes that unless action is taken by an organisation or body, there will be a risk that others may die. The organisation or body has to provide a full response to the coroner within 56 days. This can have significant implications for your business reputation and related media coverage. Please see our upcoming blog for more detail on Regulation 28 reports.

Will I have to attend? What is my role in the inquest?

If you are identified by the coroner as an Interested Person (IP) then you have the right to actively participate in the inquest proceedings. You also have the right to access the documentation held by the coroner and to question witnesses at the hearing. If you are a witness then you will need to attend the inquest and give evidence. You will be asked questions by other Interested Persons, their representatives and/or the coroner.

Being involved in an inquest, whether as an IP, a witness or both, comes with a number of responsibilities and obligations. It can be very daunting appearing in a court setting. Whilst the coroner ought to guide you through the process, you may wish to obtain legal advice so that you are fully informed in good time for the hearing and so you can choose to have representation if required.

Do I need legal representation?

Having a specialist lawyer on board can ensure you have much needed support and guidance in the months leading up to the inquest and at the inquest hearing itself, as well as dealing with any repercussions afterwards.

Legal advice can assist you in ensuring that all documentation is properly prepared and disclosed to the coroner, that key witnesses are called, that any staff who are witnessed are properly supported throughout the process. It can also help to manage any reputational damage which may arise from the issues raised in the inquest process or from a Prevention of Future Deaths report.


If you have any enquiries, please contact Ali Cloak on:

01225 730 210     Email

Leave a comment

Thank you for choosing to leave a comment. Please keep in mind that comments are moderated and please do not use a spammy keyword or a domain as your name or it will be deleted.




Health & Social Care

Part of your trusted team, on hand to provide expert advice

Learn more


T: 01225 730210 (DDI)

Search our news, events & opinions