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Briefing on Inquests

Inquests into Work-Related Deaths

What is an Inquest
Summary of what happens at an inquest
Do all work-related deaths have an inquest?
Which work-related deaths are held in front of a jury?
Purposes of the Inquest
Implications of Rule 42
Coroners Powers at an Inquest
Witnesses and questions
Pre-Inquest Disclosure of Witness Statements
Other Procedural Rules
Summing up by the coroner and Verdicts
Government Responsibility for Coroners

To see dates of work-related inquests which are due to take place in the next few months, click here
To read about recent inquests, click here
To find out about a new book on inquests published by Legal Action Group, Click Here






Government Review of Coroners Courts
The Coroners Review has published a consultation document. It is proposing that there will no longer be an automatic right for families to have an inquest into work-related deaths. To see what the inquiry says about work-related deaths, Click Here

To download the whole document, Click Here

To see CCA’s preliminary views on the Coroner's Review consultation document, click here

To see CCA press release, Click Here

What is an Inquest
It is:
• a fact finding exercise to determine the cause of violent or unnatural deaths;
• It is not a method of apportioning guilt;
• there are no parties;
• there is no indictment, no prosecution, no defence, no trial;
• It is an attempt to establish facts;
• it must be held in public;
• an inquest is held by a coroner;

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Summary of what Happens
The Coroner will:

organise a post-mortem
a few days after the death, "open" the inquest to identify the person who has died and to hear some basic evidence about how the person died;
adjourn the inquest;

During this period of adjournment, investigation will take place. In the case of a work-related death, this will be undertaken by:
• the police
• the Health and Safety Executive or Local Authority;
To read about how the police and HSE should investigated a work-related death, Click Here

If, when the investigation is over, the Crown Prosecution Service decides not to prosecute for manslaughter, the Coroner will:
• set a date for a full inquest;
• summon witnesses

At the Inquest

the coroner will ask questions of the witnesses;
other interested parties – including the family of the bereaved – can also ask questions;
a jury will return a verdict. For Work-related deaths, this is usually "accidental Death" or "unlawful killing"

If a verdict of 'Unlawful Killing' is returned by a jury - which is not a common situation - the case is referred to the Crown Prosecution Service for it to consider whether or not to posecute for manslaughter.

If not, the HSE or Local Authority will decide whether or not to prosecute a company or individual for a health and safety offence. To read more about health and safety offences, Click Here

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Do all work-related deaths have an inquest?
Section 8 of the Coroners Act states that there will be an inquest into a death when the coroner has reasonable cause to suspect that the deceased
• had died a violent or unnatural death
• had died a sudden death of which the cause is unknown
• has died in prison

An unnatural death has been defined over a century ago as a death where there is a:

"reasonable suspicion that there may have been something peculiar to the death: that it may have been due to other causes that common illness"

More recently it was suggested that a death is unnatural when it is:

"wholly or partly caused, or accelerated, by any act , intervention or omission, other than a properly executed measure interested to prolong life"

It is clear that all deaths that could be said to be "work-related" come within these definitions.

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Which work-related deaths have a jury
Section 8(3) of the Coroner's Act states that a number of types of deaths should have an inquest in front of a jury.

The pertinent ones are:

•  where "the death was caused by an accident, poisoning or disease notice of which is required to be given under any Act to a Government department, to any inspector, or other officer of a government department or to an inspection appointed under section 19 of the Health and Safety at Work Act 1974"
•  the death occurred in "circumstances the continuance or possible recurrence of which is prejudicial to the health or safety of the public or any section of the public."

Notice to a Government or inspector.
This means all deaths which must be reported to the Health or Safety Executive or Local Authority Environmental Health Departments

The Reporting of Injuries, Diseases and Dangerous Occurrences 1995 says that "where a person died as a result of an accident arising out of or in connection with work" it should be reported.

This is very wide – includes deaths of workers and members of the public
including in many different sorts of premises including for example care homes.

There are a few exceptions to this:

Most deaths resulting from the "movement of a vehicle on the road" are not reportable. However they are reportable when:

death was the result of exposure to a substance being conveyed by the vehicle
the vehicle in question was involved in "work connected with the loading or unloading or any article or substance onto or off the road
where the death involved a person undertaking construction, demolition of other work alongside the road
when the death resulted from an examination or operation in hospital
deaths reportable to the Marine Accident Investigation Branch – deaths at sea in British ship or in British Water

Possible Recurrence?
It is at the discretion of the coroner as to whether "the death occurred in circumstances the continuance or possible recurrence of which is prejudicial to the health or safety of the public or any section of the public"

Cases show that the coroner has to decide whether the circumstances that provides the context to the death were "isolated " – when no jury needs to be called - or indicates the existence of a systemic problem – where a jury should be called.

A recent book summarises the law by saying that:

"a coroner is entitled to conclude at the outset that the death resulted from circumstances that amounted to an isolated incident as opposed to a comprehensive systemic malfunction …. Thus the existence of a potential systemic defect that provides the context in which a death took place and is amenable to future prevention and/or control would justify the summoning of a jury."

























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Purposes of the Inquest
This is set out in section 36 of the Coroners Rules:

(1) The proceedings and evidence at an inquest shall be directed solely to ascertaining the following matter, namely

(a) who the deceased was
(b) how, when and where the deceased came by his death;
(c) the particulars for the time being required by the registration Acts to be registered concerning the death


(2) Neither the coroner not the jury shall express any opinion on any other matters.






The key question is what does "how" mean and in particular how widely is it be defined. This is a crucial question. It will decide what witnesses are called, how senior a company manager can be called, is it possible to argue that a company director should give evidence, what questions will be permitted.

A judge in a 1994 case stated:

"Although the word "how" is to be widely interpreted, it means "by what means" rather than "in what broad circumstances", In short the inquiry must focus on matters directly causative of death and must indeed by confined to these matters alone."

The judge went on to say

"the question of how the deceased came by his death is of course wider than merely finding the medical cause of death and it is therefore right and proper that the coroner should inquire into acts and omissions which are directly responsible for the death …

Once an inquest is held, the duty to inquire into "how the deceased came by his death" requires one then to take a broader view and investigate not merely the dominant cause but also … any acts of omission which are directly responsible for the death."

This would appear to suggest that any witness who can given evidence on any conduct that is possibly a direct cause of the death, should be allowed to give evidence.

This in itself raises questions about what is a "direct cause of the death"

It should though be noted that:

"it is not the function of a coroner’s inquest to provide a forum for attempts to gather evidence for ... future criminal or civil proceedings"

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Implications of Rule 42 on what is meant by "how"
Rule 42 of the Coroners Rules states that

"No verdict shall be framed in such a way as to appear to determine any question of:
(a) criminal liability on the part of a named person, or
(b) Civil Liability"

It is often suggested that this rule may conflict with a wider interpretation of "how". A case has however decided that any conflict must be resolved in favour of ensuring that there is a proper inquiry:

"Such conflict as may in any given circumstances appear to arise between [rule 42] and the duty to inquire ‘how’ must be resolved in favour of the statutory duty to inquire, whatever the circumstances of this may be"

It needs also to be noted that rule 42 only relates to the ‘wording’ used in the verdict not in the nature of the inquiry.

"It may be accepted that in a case of conflict the statutory duty to ascertain how the deceased came to his death must prevail over the prohibition in rule 42. The scope for the conflict is small. Rule 42 applies and applies only, to the verdict. Plainly the coroner and the jury may explore the facts bearing on criminal and civil liability. But the verdict may not appear to determine any questions of criminal liability on the part of a named person nor any question of civil liability"

In practice, therefore, rule 42 can be respected by simply the omission of a name.

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Coroners’ Power
There are not many rules determining the procedure of an inquest and it is very much up to the coroner to decide how an inquest should proceed:

As one judge has stated:

"It is the duty of the coroner as the public official responsible for the conduct of inquests, whether he is sitting with a jury or without, to ensure that the relevant facts are fully fairly and fearlessly investigated … HSE fails in his duty if his investigation is superficial, slipshod or perfunctory. But the responsibility is his. He must set the bounds of the inquiry. He must rule on the procedures to be followed"

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Witnesses and questions
It is the coroner who decides:
• who shall be called as a witness and
• what questions can be asked.

Rule 20 of the Coroners Rules states that the:

"the coroner disallow any question which in his opinion is not relevant or is otherwise not a proper question."

It states that the following people can question witnesses:

a parent, child, spouse, and any personal representative of the deceased;
any beneficiary under a policy of insurance issued on the life of deceased
the insurer who issued such a policy of insurance;
any person whose act or omission or that of his agent or servant may in the opinion of the coroner have caused or contributed to the death of the deceased;
any person appointed by a trade union to which the deceased at the time of his death belonged, if the death or the deceased may have been caused by an injury received in the course of his employment or by industrial disease
an inspector appointed by, or representative of, an enforcing authority, or any person appointed by a government department to attend the inquest
the chief officer of the police
any other person who in the opinion of the coroner is a properly interested person

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Pre-inquest Disclosure
There is no obligation on the part of the coroner to provide advanced disclosure of witness statements or other evidence.

Some are willing to provide documents if asked, other are not

In fact there is no obligation to even provide a list of witnesses. Usually, however, coroners are willing to provide this when requested

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Other Procedural Rules

The Coroner must inform any person "whose conduct is likely to be called into question at the inquest" that the inquest is going to take place. Although usually such a person will have been called to give evidence at the inquest
A coroner can, if s/he so wishes sit with an assessor. Sometimes, for example, an HSE inspector does not actually give evidence, but sits with a coroner to assist him in asking questions etc.
A person can refuse to answer a question which may incriminate himself. Rule 22 states:
(1) No witness at an inquest shall be obliged to answer any question tending to incriminate himself
(2) Where it appear to the coroner that a witness has been asked such a question the coroner shall inform the witness that he may refuse to answer.
Lawyers can not make submissions as to the "facts" of the case. They can however make submission on points of law – and in particular on what verdicts the coroner should leave to the jury

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Summing up by the coroner and Verdicts
Rule 41 states:

"Where the coroner sits with a jury, he shall sum up the evidence to the jury and direct them as to the law before they consider their verdict and shall draw their attention to rules 36(2) and 42"

The coroner will only leave - as options for the jury to return - those verdicts that s/he considers appropriate as a matter of law are justified by the evidence and safe for them to return.

There is no definitive list of verdicts. Schedule 3 of the coroners rules simply suggest some possible verdicts
• natural causes
• industrial disease of
• dependent on drugs
• want of attention at birth
• killed himself
• accident/misadventure
• killed lawfully
• open verdict
• unlawfully killed (murder manslaughter or infanticide)

For a verdict of "suicide" or "unlawful killing" the jury must be satisfied"beyond reasonable doubt" (i.e. sure)

For all the other verdicts, the jury must be satisfied "on the balance of probabilities" (i.e. more probable than not).

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Government Responsibility for Coroners
There are a number of different Government Departments with responsibility for Coroner's courts.
• The Home office has general responsibility for the coroner service;
• Local Authorities are responsible for the resourcing of coroners
• Lord Chancellor makes the 'coroners rules' which set out guidelines for how Coroners courts operate
• Attorney General has the power to to allow an application to be made to High court for new inquests

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A new book on inquests for Lawyers
Legal Action Group books published a book on "Inquests - a practitioner’s guide" on 1 October 2002. It is written by Leslie Thomas, Danny Friedman and Louise Christian. For further details contact 020 7833 7424. To download a flyer, click here (for word) or here (for PDF)

Home -> Deaths, Inquests & Prosecutions
Page last updated on November 22, 2003