An inquest is a judicial inquiry held by a coroner to determine the facts surrounding a person’s sudden, unexplained, violent, or unnatural death, or a death in state detention (e.g. in Police custody or prison). 

It is not a criminal trial and does not assign blame, but it can be highly significant, especially where state agencies may have been involved.

Purpose of an Inquest

Under Section 5 of the Coroners and Justice Act 2009, an inquest is held to determine:

• Who the deceased was
• When they died
• Where they died
• How they came by their death

If Article 2 of the European Convention on Human Rights (right to life) is engaged (e.g., deaths involving Police, prison, or mental health detention), the inquest must also explore the wider circumstances of the death, not just the immediate cause.

Types of Verdicts (Conclusions)

Coroners or juries may return:

• Short-form conclusions: e.g. natural causes, accident, suicide, misadventure, unlawful killing, or open conclusion
• Narrative conclusions: A factual account of the circumstances, especially in complex or Article 2 cases

Who Can Attend or Participate?

• Interested persons may include:
  • Family members
  • Police, prison, or healthcare staff
  • State bodies (e.g., NHS Trusts, Home Office)
  • Anyone whose actions may have contributed to the death

Role of Legal Representation

Although inquests are fact-finding (not adversarial), families and state bodies often have legal representatives. Lawyers can:

• Make submissions
• Cross-examine witnesses
• Ensure proper disclosure
• Raise Article 2 issues

Families may be eligible for Legal Aid, particularly where there's a public interest or Article 2 inquest.

Timing and Process

• Death reported to coroner
• Pre-inquest review hearing(s), especially in complex cases
• Full inquest hearing - can last from 1 day to several weeks
• Conclusion delivered - short-form or narrative

Potential Outcomes

• Highlight failings in care, Police conduct, or systemic issues
• Trigger PFD reports (“Preventing Future Deaths”) requiring agencies to act
• Support future civil claims (e.g., under the Human Rights Act or negligence)
• May lead to criminal or disciplinary investigations, though inquests themselves don’t assign criminal liability

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