Coroner’s Inquests

At Blake Lapthorn solicitors we believe that the coroner’s inquest is a valuable opportunity in the process of thoroughly investigating the medical circumstances of a patient’s death. It provides early disclosure in the form of witness statements from the relevant medical staff, and the questioning of those staff in a public forum.

The coroner’s duty is to enquire as to the cause of the deceased’s death and the circumstances in which it occurred. We believe the deceased’s family need careful and sensitive advice to help them through the unfamiliar and daunting experience of an inquest.

We are able to offer experienced advice and advocacy services for coroner’s inquests. We can provide an early assessment of cases, as well as representation and support for families. Click on the links below for more information:

updated news... Blake Lapthorn acts on behalf of clients at Gosport War Memorial Hospital inquests.

For further information please complete the contact us form or contact the Clinical Negligence team in Southampton on 023 8085 7271, London on 020 7814 6902 or Oxford on 01865 248607 or email clinicalnegligenceinfo@bllaw.co.uk.

purpose of inquest

The inquest brings together lawyers, medical professionals, the coroner, and the family to analyse in detail events in the life of the deceased leading to their death. The inquisitorial nature of the proceedings means that, strictly speaking, there are no parties. There are therefore no ‘sides’ to advance cases and it is the coroner who leads the inquiry rather than holds a trial. Clearly, however, the stakes are high for all concerned. It is therefore important for clients to understand the benefits, strengths and limitations of the procedure.

The coroner cannot provide a verdict that would attribute either civil liability, or criminal liability, to a named person because those are determinations to be reached in the civil or criminal courts. Nevertheless, the fact-finding process and observations by the coroner can have a great effect on individuals or institutions whose actions may subsequently become the subject of criticism or legal actions.

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initial advice

We advise families to help them understand the inquisitorial process of a coroner’s inquest and, if they wish, we can represent them at the inquest. We will ask the family:

has a formal complaint already been made to the hospital, or other medical professional?
are medical records available?
has the coroner released any statements?
has the coroner released the post mortem report?

Assuming that the family would like legal representation, we notify the coroner as soon as possible. We request disclosure of any available documentation, review it, and we look at the likely scope of the inquiry. Generally, this means forming a view on the witness evidence, and medical expert evidence, that the coroner proposes to call.

The coroner has discretion as to what evidence is called. However, representations can be made in writing or at a pre-inquest hearing. We believe that representations and good communication should be established early with the coroner and his officers, to avoid the possibility of procedural delays or adjournments dealing with evidential issues.

A few weeks before the inquest, we like to meet with families, discuss their concerns about the events, go through all the evidential details, discuss the procedures, give legal advice and support, and deal with questions. We also go through the documentation with families, and discuss the options available with regard to representation, as well as the likely costs.

Having reviewed the documentation, we will advise families about:

our view of the evidence which the coroner proposes to call
the scope for any additional evidence
our analysis of the issues surrounding the medical cause of death
our analysis as to culpability of the various hospitals and medical practitioners involved
the types of verdicts that the coroner may make – natural causes, accidental death, misadventure, neglect, unlawful killing and narrative verdicts
the application of article two of the Human Rights Act 1998
the application of coronial law to the facts of the case; and procedures in the coroner’s court, including practical matters

We will ascertain the likely length of the inquest, and the number of witnesses and experts to be called. This is important preparation, and enables us to advise on the likely cost of representation.

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funding the case

The general position is that Legal Aid funding for inquests is only available in 'exceptional circumstances' – usually when human rights law is an issue. Consequently, for most medical incidents, families will meet their costs either through:

private funding or
their legal expenses insurance

Often a civil clinical negligence claim for compensation may be made after the inquest. In those cases, the costs of the inquest might be included as part of the costs of investigating the clinical negligence claim. In some circumstances, Blake Lapthorn solicitors may be able to enter in to funding arrangements such as a conditional fee agreement – ie 'no win, no fee basis' - to cover the costs of representation at the inquest by claiming these within the damages of a subsequent clinical negligence claim.

When considering the costs, the following factors will be relevant:

anticipated length of hearing
amount of case papers and associated preparation time
whether a solicitor or a barrister acts as advocate
instructing independent medical experts

We always discuss the likely costs with families, and will offer a range of helpful options. In certain circumstances, particularly where there are young dependents, we may consider waiving our normal fees for our work in relation to the inquest.

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coroner’s hearing

Generally, we meet early before the hearing. We believe that providing supportive and helpful guidance can help to ease some of the pressures. Even if family members are not giving witness evidence, it can be an extremely stressful occasion. They will see the doctors who treated their relative giving evidence in the witness box and answering questions about that treatment.

The coroner leads the inquiry, and the questioning. Although a coroner’s inquest is not a trial, the venue and atmosphere of the inquest is that of the courtroom. Depending upon the issues, the coroner may take evidence from a pathology expert either first or last, and hear the other witnesses, usually the treating clinicians, accordingly.

After the coroner’s questions, the legal representatives or a spokesperson for the family has an opportunity to question and cross-examine the witnesses. Care must be taken that the questions are limited to the scope of the inquiry. Whilst the coroner will allow some questions relevant to liability to be put to the witnesses, where they touch on the circumstances of the deceased’s death, he may be forced to disallow questioning which appears directly to invite a verdict making a ruling on liability.

All the evidence of the hearing is taped. A transcript can be obtained after the hearing on payment of a transcript fee to the coroner’s office.

Many inquests are dealt with in half, or sometimes, a whole day. Usually, the coroner will give his verdict on the same day. He will ask the legal representatives for their submissions and representations, usually before adjourning for a short while to consider and prepare his verdict, which is read out by him in open court.

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verdicts

The usual verdicts encountered are death due to 'natural causes', 'accident/misadventure’ – sometimes a 'narrative verdict', occasionally that 'neglect contributed to the death' or – very infrequently that of 'unlawful killing'. Considerable significance is often placed by family members and representatives on the final short form verdict, if used. However, it is important to realise that the verdicts are framed in terms of the cause of death and not so as to express a view on legal culpability.

Narrative verdict

A coroner may choose to give a narrative verdict. Although standard descriptions may be used, the only legal requirement is that the coroner gives a clear and concise statement. Whilst these can be phrased neutrally, there is greater potential for actual or implied criticism of the actions taken in the circumstances leading to the death of the deceased.

Neglect verdict

The coroner may find that a death has occurred because of neglect. It is usually expressed that the cause of death was “contributed to by neglect”. When looking at medical incidents this is effectively a finding of “gross negligence” against the hospitals or medical staff involved. Coronal case law has evolved to define further the concept of “gross” failures.

Generally under case law, certain criteria must be fulfilled for the coroner to make a ”neglect verdict”’. For example, a failure to provide any treatment at all to a vulnerable person; or clear or gross failure, such as failing to carry out basic medical monitoring procedures. It used to be that there had to be a failure to provide treatment based on the patient’s condition as it appeared to the medical staff. We believe now that the appropriate test is what the medical staff 'should' have known about the patient’s condition, if appropriate practices and procedures were followed. In addition to the nature of the failings in the care, it must also be shown that:

'but for' the neglect, the deceased would have survived or
the 'neglect' significantly contributed to the deceased’s death

Although the purpose of the inquest is to examine the factual circumstances of the death, a verdict of neglect will mean that the family is in an extremely strong position if they then decide to bring civil proceedings in a clinical negligence claim.

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Human Rights Act 1998

The part of the Human Rights Act that sometimes has relevance to a coroner’s inquest into a death is the 'right to life'. This is combined with the 'procedural requirement' that when deaths occur there must be an effective method for investigation of the facts; that process should enable the families properly to be involved. All public bodies are under a duty to comply with human rights law and this includes the courts and the coroner’s court.

Where an individual’s life is directly dependent upon a state organisations, such as an NHS Trust, there may be an issue under human rights law. The state itself is under an obligation to provide appropriate health care services and to maintain proper standards. We believe therefore that the same standard of enquiry will apply to private hospitals as it does to the NHS. These obligations reflect the state’s duties to respect and uphold the 'right to life'.

The state is not only under a duty to protect the right to life, but also to have in place proper procedures, which may include the processes in the civil or criminal courts, to undertake a proper inquiry where there may have been a breach of that right. In these circumstances, the scope of the investigative duty may outweigh the usual restrictions on the scope of the coroner’s inquiry. This is to enable the state to fulfil its obligation to investigate. These are the types of cases where Legal Aid funding may be available under “exceptional” circumstances for the families’ costs relating to the inquest.

Examples of the implications of this approach will be:

deaths in custody
deaths where a patient is detained under the Mental Health Act
systemic failures in the state’s institutions
where there is the need to avoid deaths from occurring in similar circumstances in the future

At Blake Lapthorn solicitors we provide expert advice, drawing upon our clinical negligence lawyers and human rights law specialists.

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purpose of inquest

initial advice

funding the case

coroner’s hearing

verdicts

Human Rights Act 1998

clinical negligence

resources

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