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  • Inquests: An essential guide

Introduction to inquests

An inquest is a public court hearing held by a coroner in certain circumstances to decide who died and how, when and where the death happened. At the inquest, the coroner will hear from witnesses and consider other evidence, such as post-mortem or expert reports.

An inquest is an inquisitorial process with the aim of establishing facts, rather than apportioning blame. At the end of an inquest, the coroner, having considered the evidence, will reach a conclusion about the death.

Why are inquests held?

Inquests are formal investigations, with the primary aim to establish the identity of the deceased, as well as the time, place, and manner of death. They are only required in cases where these details are unclear or uncertain.

As a doctor or healthcare professional, you may be called upon as a witness or an "Interested Person" to aid the inquiry by providing context or clarity around the circumstances of the death.

The coroner's inquiry may reveal causes for the death that necessitate legal recourse. Your testimony may be critical to the inquest's findings.


The coroner can also write a report in cases where the evidence presented at the inquest suggests that further avoidable deaths could occur and that, in the coroner’s opinion, preventative action should be taken.

An inquest can take anything from less than one hour to a few weeks, depending on the complexity of the circumstances surrounding the death. It will usually take place as soon as possible after the death and within 6 months, if possible. It will not usually take place until all other investigations into the death have been completed. This may be an investigation by the police, the pathologist, or any other external investigation that the coroner has requested or that an outside agency is undertaking. This allows the coroner to consider all of the information relating to the death at the inquest.

Not all deaths that are investigated by a coroner need to have an inquest.

Reporting to the coroner

A death may be reported to the coroner by different people, such as the police, prison officers, the registrar of births and deaths, doctors or a hospital. When a death is reported, the coroner first carries out enquiries to see if they can find the cause of death quickly. If they can, and the death was due to natural causes, in most cases the coroner has no further role. If the cause of death is still not known or falls into a certain category of death then the coroner will carry out further enquiries to find out the cause of death.

Coroners are independent judicial office holders, usually lawyers, appointed by local authorities. They work within a legislative framework and, under section 1 of the Coroners and Justice Act 2009, a coroner has a duty to investigate a person’s death if the deceased’s body is within the coroner’s area and if they have reason to suspect that:

  • the deceased died a violent or unnatural death
  • the cause of death is unknown, or
  • the deceased died while in custody or otherwise in state detention or while detained under the Mental Health Act 1983.

Several other categories of death should be reported to the coroner. These include:

  • when the deceased was not seen by the certifying doctor either after death or within 14 days before death
  • the death may be due to an accident (whenever it occurred)
  • the death may be due to self-neglect or neglect by others
  • the death may be due to an industrial disease or related to the deceased's employment
  • the death occurred during an operation or before recovery from the effects of an anaesthetic
  • for any other concerning feature

When a death is reported to a coroner, they will make preliminary inquiries to decide if an investigation is required. Coroners are supported by coroner’s officers who are usually employed by either the local police service or the local authority. Coroner’s officers support the coroner in their investigation, communicate with relatives, and make inquiries at the direction of the coroner.

In Scotland if a death occurs in a violent or unnatural manner, in custody, or suddenly but without certain cause, the Procurator Fiscal has a duty to inquire into the death. This factsheet sets out the role of the Procurator Fiscal, the reporting process, and what will happen once a death is reported to a death to the Procurator Fiscal.

Providing a statement

When investigating an individual's death, the coroner will obtain reports or statements from those directly involved with the deceased before death, particularly the deceased’s GP and any hospital doctors providing care to the deceased in the lead-up to their death.

When providing a written statement, a healthcare professional must provide factual information to assist the coroner. There is a legal and professional obligation to cooperate with formal inquiries, such as inquests, so all relevant information should be provided.

A statement for the coroner should be detailed, clear and objective and based on medical records, personal recollection and usual practice. The statement should usually contain:

  • An opening paragraph including details of qualifications, experience, current role, and role at the material time, if this was different.
  • An overview of the patient’s medical history and medications and the statement written chronologically. Each relevant consultation should be described in such a way that it is clear what history was obtained from the patient and what the findings of any examination were, along with the working diagnosis and the rationale for reaching that diagnosis. The management plan should be explained, and any medical terminology should be defined in lay language. If blood results or observation readings are provided, the normal values and the units of these should also be provided.
  • If specific questions have been asked, then these should be addressed.
  • It should be made clear when the individual clinician’s involvement with the patient ended, and it is appropriate to end the statement with an offer to provide further information or clarification should it be required.
  • The final version of the statement should be signed and dated.

It is not usually appropriate to simply provide a copy of the relevant medical records, and this may be more likely to result in a summons to attend the inquest in order to explain the entries and provide additional information.

Further guidance is available on report writing here.

Medical Protection can help and advise members on the content and structure of a statement for the coroner. The hospital legal team can also assist hospital-based practitioners with their statements and may be involved in coordinating several statements for the coroner where a death has occurred in the hospital or shortly after discharge.

The coroner's inquiry

The coroner may decide to hold an inquest as part of their investigation. The law says that the coroner must open an inquest into a death if there is reasonable cause to suspect that the death was due to anything other than natural causes i.e a natural disease process running its natural course, or where the death occurred in state detention.

An inquest is held in public and is a formal court proceeding. There is no defence and prosecution as it is not a function of the coroner to apportion blame – the coroner’s court is one of investigation and inquiry; it is not adversarial, but it is important to understand that the parties attending an inquest may include the bereaved family, hospital or other service providers, as well as individual clinicians.

All may have legal representation and be cross-examined on their evidence. The inquest is an opportunity for a family and the coroner to seek answers to questions directly from the deceased’s healthcare providers - so it is essential to be prepared.

The inquest may be held with or without a jury depending on the circumstances of the death. Although the Coroner has discretion to sit with a jury, the coroner must do so in cases of unnatural deaths of individuals in state detention.

During an inquest itself, the coroner will question the witnesses, followed by questions from any Interested Persons (IP’s), including the family of the deceased or their legal representative. As mentioned above, an inquest is inquisitorial rather than adversarial; however, many healthcare professionals understandably find it stressful to be questioned in these circumstances.

Read our case studies on: Inquests

Case report 15/08/2023

Manslaughter investigation leads to inquest

Manslaughter investigation leads to inquest

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Appearing as a witness

A coroner can call a person to give evidence at an inquest under Schedule 5 of the Coroners and Justice Act 2009. This power compels a person to produce evidence to a coroner if requested, usually by way of a written statement or documents in the custody of that person, such as medical records.

It is an offence to fail to attend an inquest when summonsed (without a reasonable excuse), give false evidence, distort, alter or prevent any evidence or document being provided for the purpose of an investigation, or to intentionally suppress, conceal or destroy any document a person knows or believes to be relevant to such an investigation. Such offences amount to contempt of court and, under Schedule 6 of the Coroners and Justice Act 2009, are punishable by a fine up to £1,000, imprisonment of up to 51 weeks, or both. Failure to comply with a coroner’s investigation could also result in a referral to the relevant professional regulator, for example, the General Medical Council (GMC).

A healthcare provider can be called to attend an inquest as a witness in one of two ways:

  • As a "Witness of Fact"
    If called as a witness of fact, it would usually indicate that the coroner believes involvement in the case may take them through it, asking relevant questions, in order to clarify certain aspects.
  • As an "Interested Person"
    If called as an Interested Person (IP) this would indicate that the coroner believes an individual to be more centrally involved in the circumstances leading to death. If granted IP status, then legal representation is permitted; in these circumstances, it is also permissible to receive disclosure of the documents that the coroner intends to rely upon at the inquest and ask questions of other witnesses.

When asked to attend an inquest, it is helpful to know from the outset on which basis an individual has been asked to attend. An NHS hospital-employed doctor or healthcare provider will usually be represented at an inquest by their employer.

When a healthcare professional is self-employed - in general practice, for example - working privately or for a private hospital or agency, or in cases where there is a potential conflict between an individuals’ interests and those of their employer, then separate legal representation is advised and if appropriate, can be provided through Medical Protection.

Giving evidence during an inquest

Witness evidence is given under oath, meaning there is a legal obligation to tell the truth at an inquest.

When giving evidence, it is important to ensure familiarity with any written statement and the medical records and have these to hand. If attending to give evidence in person, arrive in good time. If providing evidence remotely, it is recommended to have a test run with the court in advance and have a quiet, private room to give evidence.

When speaking to the coroner or answering questions from other parties, speak clearly and ensure any medical terms are explained. Answer any question openly and honestly, but do not try to predict what the coroner might ask next and answer pre-emptively – the coroner will seek further information as required.

Do not be alarmed or leap to fill the silence if there is a pause after speaking. The coroner may require a brief period of time to make notes or consider their next question. If a question is not understood, clarity can be sought.

At all times, the tone of voice should be explanatory and non-confrontational


Additional information about giving evidence can be found here.

Conclusions and prevention of future death report

At the end of the inquest, once all of the evidence has been considered and heard, the coroner will reach a conclusion. This includes the legal determination stating formally who died, and where, when and how they died.

The coroner may come to a ‘short form’ conclusion and use one of the following terms:

  • Accident or misadventure
  • Alcohol/drug related
  • Industrial disease
  • Natural causes
  • Open (used when there is insufficient evidence for any other outcome)
  • Road traffic collision
  • Stillbirth
  • Suicide

Alternatively, or in addition, the coroner may make a brief ‘narrative’ conclusion, setting out the facts surrounding the death in more detail and explaining the reasons for the decision.

A coroner’s conclusion can only be challenged through judicial review in the High Court. Legal proceedings must be initiated as soon as possible but no later than three months following the inquest's conclusion.

In cases where the evidence suggests that further avoidable deaths could occur and that, in the coroner’s opinion, preventative action should be taken, the coroner is obliged under the Coroners and Justice Act 2009 to make reports to a person, organisation, local authority, or government department or agency to prevent future deaths. This is commonly known as a Prevention of Future Death Report (PFD) or a Regulation 28 report.

The PFD report will be sent to the appropriate authority (for example, the NHS authority or GP Practice that had care of the deceased before death) to review the issues. This authority then has 56 days to respond in writing under the Coroners (Investigations) Regulations 2013. These reports are now routinely published on www.judiciary.gov.uk, which means that they are publicly accessible.


Notifying the regulator and health authority

Doctors have a duty to inform their regulator, the GMC, without delay in circumstances when they have been criticised by an official inquiry, which would include a coroner’s inquest. The coroner can also refer a healthcare professional to their regulatory body if they consider that it would prevent a recurrence of the incident that caused the death.

In England and Wales, the National Health Service (Performers Lists) Regulations place performers (GPs) under an obligation to inform the relevant health authority if the coroner finds that the performer’s actions caused or contributed to the deceased's death or otherwise brought their conduct into question at an inquest.

Medical Protection can advise and assist members when asked to provide a statement to a coroner or give evidence at an inquest and encourages members to call Medical Protection when information from a coroner is first sought.

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