Coroner’s Inquest | Procedure and Disclosure | KANGS Coroner’s Inquest Solicitors


A Coroner’s Inquest is an investigation to determine the cause of death of an individual.

An Inquest is a Public Hearing, held with or without a jury, during which the Coroner may consider both oral and written evidence.

At the end of a Hearing, the Coroner will deliver his conclusion as to the course of death.

Helen Holder of KANGS outlines the general nature and procedure of a Coroner’s Court.

The Team at KANGS is led by Hamraj Kang, who is individually ranked by the leading directories in the ‘Top Tier/Star Individual/Hall of Fame’ of criminal solicitors, and KANGS is ranked in the Top Tier of criminal law firms in the Legal 500 and Chambers UK.

Should you require any initial advice, our Team can be contacted as follows:

Coroner Inquests | Participants and Procedure | KANGS Inquest Solicitors

A Coroner, is an independent judicial officer, appointed by the local authority, being a lawyer or doctor responsible for investigating the circumstances and course of death under section 5 Coroners and Justice Act 2009 (‘the Act’) to ascertain:

  • the identity of the deceased
  • how, when and where the deceased came by his or her death and
  • any particulars required by the Births Deaths and Registrations Act 1953 to be registered concerning the death.

Coroner’s proceedings involve a number of parties including those deemed ‘interested persons’ under s.47(2) of the Act which states:

‘ “Interested person”

(1) This section applies for the purposes of this Part.

(2) “Interested person”, in relation to a deceased person or an investigation or inquest under this Part into a person's death, means—

(a) a spouse, civil partner, partner, parent, child, brother, sister, grandparent, grandchild, child of a brother or sister, stepfather, stepmother, half-brother or half-sister;
(b) a personal representative of the deceased;
(c) a medical examiner exercising functions in relation to the death of the deceased;
(d) a beneficiary under a policy of insurance issued on the life of the deceased;
(e) the insurer who issued such a policy of insurance;
(f) a person who may by any act or omission have caused or contributed to the death of the deceased, or whose employee or agent may have done so;
(g) in a case where the death may have been caused by—

(i) an injury received in the course of an employment, or
(ii) a disease prescribed under section 108 of the Social Security Contributions and Benefits Act 1992 (c. 4) (benefit in respect of prescribed industrial diseases, etc), a representative of a trade union of which the deceased was a member at the time of death;

(h) a person appointed by, or representative of, an enforcing authority;

(i) where subsection (3) applies, a chief constable;
(j) where subsection (4) applies, a Provost Marshal of a service police force or of the tri-service serious crime unit;

(k) where subsection (5) applies, the Director General of the Independent Office for Police Conduct;

(ka) where subsection (5A) applies, the Service Police Complaints Commissioner;

(l) a person appointed by a Government department to attend or follow an inquest into the death or to assist in, or provide evidence for the purposes of, an investigation into the death under this Part;

(m) any other person who the senior coroner thinks has a sufficient interest’


Most deaths are not reported to the Coroner and the deceased's doctor will issue a Medical Certificate showing the cause of death.

All citizens have a common duty to provide information to a Coroner of circumstances where an inquest should be held and it is an offence to obstruct a Coroner by disposing of a body before a Coroner can investigate the circumstances of a death or by acting in a manner preventing an inquest.

A Coroner’s duty to investigate arises under section 1(1) and (2) of the Act which states:

‘Duty to investigate certain deaths.

(1) A senior coroner who is made aware that the body of a deceased person is within that coroner's area must as soon as practicable conduct an investigation into the person's death if subsection (2) applies.

(2) This subsection applies if the coroner has reason to suspect that—

(a) the deceased died a violent or unnatural death,
(b) the cause of death is unknown, or
(c) the deceased died while in custody or otherwise in state detention.’

Once a duty arises upon a Coroner:

  • an Opening Hearing announces that an investigation has commenced and will be adjourned pending conclusion of investigations. Interested persons may make submissions on potential areas of investigation.
  • a post-mortem examination will be conducted. A bereaved of the deceased is not allowed to attend the autopsy but may send a medical representative on their behalf.
  • a post-mortem should occur within twenty-eight days of a coroner becoming aware of a body. After this period, the body should be released to the bereaved. This period may be extended, but a coroner must explain the reasons for the delay.
  • once the Coroner has decided whether or not to hold an Inquest, the Coroner will refer the death to the police if considered appropriate, whereafter, the Coroners’ proceedings will be stayed until the end of the Police investigation.
  • where the matter is not reported to the Police, a timetable will be set for the remainder of any enquiries to be concluded and, where required, a Pre-Inquest Hearing will be held.
  • once all procedural matters have been concluded, the Hearing will take place, the evidence will be considered by the Coroner who will present his conclusions.

Disclosure of Documents

Disclosure is limited to interested persons and a Coroner must disclose relevant documents at any stage of an Investigation.

Relevant documents encompass any medium in which information of any description is recorded or stored and includes photographs, CCTV footage and paper documents.

Disclosure must be conducted as soon as reasonably practicable.

Rules of disclosure are dictated by the Coroner’s (Inquest) Rules 2013 (‘the Rules’):

‘Disclosure of documents at the request of an interested person

13.—(1) Subject to rule 15, where an interested person asks for disclosure of a document held by the coroner, the coroner must provide that document or a copy of that document, or make the document available for inspection by that person as soon as is reasonably practicable.

(2) Documents to which this rule applies include—

(a) any post-mortem examination report;
(b) any other report that has been provided to the coroner during the course of the investigation;
(c) where available, the recording of any inquest hearing held in public, but not in relation to any part of the hearing from which the public was excluded under rule 11(4) or (5);
(d)any other document which the coroner considers relevant to the inquest.

Restrictions on Disclosure
15.  A coroner may refuse to provide a document or a copy of a document requested under rule 13 where—

(a) there is a statutory or legal prohibition on disclosure;
(b) the consent of any author or copyright owner cannot reasonably be obtained;
(c) the request is unreasonable;
(d) the document relates to contemplated or commenced criminal proceedings; or
(e) the coroner considers the document irrelevant to the investigation.’.

Inquest Conclusions

There is no definitive list of conclusions available to a Coroner but frequently given findings are:

  • natural causes,
  • accidental death or misadventure,
  • alcohol/drug related abuse,
  • industrial disease,
  • lawful/unlawful killing,
  • road traffic collision,
  • stillbirth,
  • suicide,
  • open cause of death, when there is not enough evidence to decide on any other conclusion.

Narrative conclusions

The Coroner is entitled to explain the facts surrounding a death in detail highlighting the main issues and is not bound by any particular determination, such as those frequently given as mentioned above.

However, the conclusion reached needs to be concise and explain how the death arose.

Such conclusion must be based on the civil law standard of proof of ‘the balance of probability’ i.e., it is more likely than not that the death occurred in a particular way.

Prior to Maughan, R (On the application of) v Her Majesty’s Senior Coroner for Oxfordshire [2020] UKSC 46 the standard of proof required was that of ‘beyond reasonable doubt’, as applied in criminal courts, but the Supreme Court reversed this approach.

Suspected death by homicide

Whilst a Coroner’s Investigation cannot compel a law enforcement agency to re-open any Investigation, after an Inquest finding of ‘unlawful killing’ a Coroner is required to adjourn an Inquest and notify the Director of Public Prosecutions.

The Rules state at section 25 (4):

 ‘A coroner must adjourn an inquest and notify the Director of Public Prosecutions, if during the course of the inquest, it appears to the coroner that the death of the deceased is likely to have been due to a homicide offence and that a person may be charged in relation to the offence.’

How Can We Assist? | KANGS Coroner’s Inquest Solicitors

Should you receive communication from the coroner’s office informing you that you are an interested party, whether either a witness, a bereaved, a person who is alleged to have contributed to another’s death or any other relevant person, it is important to seek immediate legal advice.

Clearly, any proposed appointment of a Coroner may occur at an immensely emotional time when the thought of any kind of involvement with any legal proceedings will be distressing.

The Team at KANGS fully appreciates and emphasises with those facing the potential of an Inquest and will guide and sympathetically advise throughout these difficult times.

If we can be of assistance, please do not hesitate to contact us by telephone 0333 370 4333 or email info@kangssolicitors.co.uk or contact one of our Team shown below.

Hamraj Kang

Hamraj Kang
Senior Partner

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