into Work-Related Deaths
What is an Inquest
Summary of what happens at an inquest
Do all work-related deaths have an
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
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
To read about recent inquests, click
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
To see CCAs preliminary views on the Coroner's
Review consultation document, click
To see CCA press release, Click
is an Inquest
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:
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
During this period of adjournment, investigation will
take place. In the case of a work-related death, this
will be undertaken by:
the Health and Safety Executive or Local Authority;
To read about how the police and HSE should investigated
a work-related death, Click
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;
coroner will ask questions of the witnesses;
interested parties including the family
of the bereaved can also ask questions;
jury will return a verdict. For Work-related deaths,
this is usually "accidental Death" or
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
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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
has died in prison
An unnatural death has been defined over a century
ago as a death where there is a:
suspicion that there may have been something peculiar
to the death: that it may have been due to other
causes that common illness"
recently it was suggested that a death is unnatural
when it is:
or partly caused, or accelerated, by any act , intervention
or omission, other than a properly executed measure
interested to prolong life"
is clear that all deaths that could be said to be
"work-related" come within these definitions.
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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.
pertinent ones are:
"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"
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."
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
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
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:
deaths resulting from the "movement
of a vehicle on the road" are not
reportable. However they are reportable
was the result of exposure to a substance
being conveyed by the vehicle
vehicle in question was involved in
"work connected with the loading
or unloading or any article or substance
onto or off the road
the death involved a person undertaking
construction, demolition of other
work alongside the road
the death resulted from an examination or
operation in hospital
reportable to the Marine Accident Investigation
Branch deaths at sea in British ship
or in British Water
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:
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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of the Inquest
This is set out in section 36 of the Coroners Rules:
The proceedings and evidence at an inquest shall
be directed solely to ascertaining the following
the deceased was
when and where the deceased came by his
particulars for the time being required
by the registration Acts to be registered
concerning the death
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:
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."
judge went on to say
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
acts of omission which are directly responsible
for the death."
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:
is not the function of a coroners inquest
to provide a forum for attempts to gather evidence
for ... future criminal or civil proceedings"
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of Rule 42 on what is meant by "how"
Rule 42 of the Coroners Rules states that
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,
(b) Civil Liability"
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.
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
practice, therefore, rule 42 can be respected by simply
the omission of a name.
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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:
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
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
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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:
coroner disallow any question which in his opinion
is not relevant or is otherwise not a proper question."
states that the following people can question witnesses:
parent, child, spouse, and any personal representative
of the deceased;
beneficiary under a policy of insurance issued
on the life of deceased
the insurer who issued such a policy of insurance;
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;
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
inspector appointed by, or representative of,
an enforcing authority, or any person appointed
by a government department to attend the inquest
chief officer of the police
other person who in the opinion of the coroner
is a properly interested person
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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
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
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
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.
person can refuse to answer a question which may
incriminate himself. Rule 22 states:
witness at an inquest shall be obliged to
answer any question tending to incriminate
it appear to the coroner that a witness
has been asked such a question the coroner
shall inform the witness that he may refuse
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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up by the coroner and Verdicts
Rule 41 states:
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"
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
industrial disease of
dependent on drugs
want of attention at birth
unlawfully killed (murder manslaughter
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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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
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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new book on inquests for Lawyers
Legal Action Group books published a book on "Inquests
- a practitioners 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