The inquest is the term used to refer to the actual court proceedings where the coroner's initial investigations are that the cause of death is undetermined. The inquest is a public, fact-finding inquiry solely directed to ascertaining who the deceased was (their name), along with how, when and where they came by their death. In some situations, the coroner will conduct an Article 2 inquest which is much wider in scope and will look at the circumstances by which the deceased individual came by their death.

It is a fact-finding inquiry and so no blame will be apportioned to any individual or organisation. However, attending an inquest can be confusing, distressing and worrying for witnesses who are asked questions about their knowledge and involvement with the deceased prior to their death, especially as there may be a risk of potential civil action taken if, for example, a finding of negligence has been found as a contributing factor.

The coroner directs the proceedings at an inquest which must be held in public. Therefore, anyone is able to attend and watch the proceedings. All of the witnesses must have provided the coroner with a signed witness statement setting out their contact or involvement with the deceased just prior to their death. The coroner will have decided in advance of the inquest which witness statements will be read out and which witnesses will be required to attend to give further information.

The coroner will decide which order the witnesses present their evidence and will use the statement as guidance but will also ask questions of the witness to assist in their understanding of how the deceased came by their death. Once the coroner has asked questions, the family of the deceased are permitted to ask questions of the witness followed by the legal representatives of any Interested Parties. Thereafter, the legal representative of that particular witness may ask questions to clarify any matters.

Once all of the witnesses have given evidence, the Interested Parties, normally through their legal representatives, may address the coroner on potential conclusions that may be reached as to the cause of death. This is particularly important when the issue of negligence is being considered as a potential causative factor. This is because it could result in a civil claim being brought by the family to that individual or organisation. They are also able to address the coroner on whether or not action needs to be taken to prevent any future deaths (PFD) from being caused. This is a very important stage in the inquest and specialist legal advice is essential as the ramifications from a PFD can be expensive and result in adverse publicity for the organisation concerned.

Some investigations prior to an Inquest unfortunately take longer than others depending upon what material has been requested by the coroner. The coroner may have asked for medical reports to be obtained from experts or local authorities may have conducted their own investigations and the coroner may request a copy of these reports and outcomes. However, the Coroner's (Inquests) Rules 2013 require that an inquest must be completed within 6 months, or as soon as reasonably practicable thereafter.

There are sometimes outside factors which may cause a delay and affect how long an inquest takes to be heard. For example, the COVID-19 pandemic, with subsequent lockdowns and safety measures put in place, caused significant disruption and a backlog of inquests to be carried out.

All inquests are different. Some may take an hour whilst others may take a day or a week. It all depends upon how many witnesses are required to attend at the inquest together with the length of time taken to be asked questions by the legal representatives of the Interested Parties.

However, all inquests are in public so anyone can attend and watch the proceedings. They are also recorded and evidence is given on oath by each witness, which is a promise to tell the coroner the truth. It is therefore essential that expert legal advice is obtained as soon as you suspect that the coroner may wish to hear about your involvement so that your full knowledges of the circumstances surrounding an individual's death can be explored.

There are two different types of coroner's inquest, although the term is often used as a catch-all for either of these. They are most commonly known as Jamieson Inquests and Article 2 Inquests, with the latter sometimes referred to as Middleton Inquests.

Jamieson Inquests

This is the most basic form of inquest, where the coroner simply deals with the four essential questions and does not look at the wider circumstances surrounding the death.

• Who was the deceased?

• Where did they die?

• When did they die?

• How did they die?

Middleton Inquests or Article 2 Inquests

An Article 2 inquest, sometimes also referred to as a Middleton inquest, includes a wider investigation into the circumstances of the death. The coroner will look at not just how the deceased died, but also look deeper into the context and background of the death.

Article 2 inquests are often engaged if someone has died whilst in the care of the state e.g. in police custody, in immigration detention or whilst sectioned under the Mental Health Act. This type of inquest may also be held where it is thought that policy or failures in a system have caused someone's death e.g. where a death might be due to unsafe policies in a hospital.

If you are unable to attend an inquest but wish to find out the verdict and see details of the investigation, a copy of the official reports can be requested from the relevant coroner's office once the inquest has concluded. There is usually an administration fee to pay for this, which the coroner's office will inform you of.