A coroner is an independent judicial office holder. Coroners investigate deaths that have been reported to them if it appears that the death was violent or unnatural, where the cause of death is unknown or where the person died in prison, police custody, or another type of state detention.
Coroners are appointed by and paid by the local authority for their area but they are independent of the local authority and government.
The work of coroners is overseen by the Chief Coroner who is the head of the coronial system, providing national leadership for coroners in England and Wales. The current Chief Coroner is His Honour Judge Thomas Teague QC.
In particularly complex cases (for example where there are multiple deaths) a judge may be appointed to oversee the inquest.
An inquest is a fact-finding exercise. The purpose of an inquest is to establish the answers to the four questions posed in section 5 of the Coroners and Justice Act 2009.
If the Coroner decides that Article 2 of the European Convention on Human Rights (as enacted through the Human Rights Act 1998) is engaged, the coroner’s investigation to answer ‘how’ someone died will be wider and consider both by what means and in what circumstances they died.
It is important to note that the proceedings and evidence are aimed only at determining the answers to these questions and are not a mechanism for apportioning civil or criminal liability against a named individual. If evidence is found, however, that suggests an individual or organisation may be to blame for the death, then a coroner can pass all the evidence gathered to the appropriate authorities.
The Coroner held a pre inquest review on 30 March 2021. Further pre inquest review hearings will be held this year. It is anticipated that the main inquest hearings will take place in 2022.
Pre inquest review hearings will be held at the Royal Courts of Justice in London. Enquiries will be made as to whether there are any suitable venues for the main hearings to be held in Salisbury. It is likely that at least some of the main hearings will be held in (or near to) Salisbury.
The majority of inquests will be heard without a jury. However, there are certain circumstances where a jury must be called, including where the death occurred in custody or as a result of an accident at work. A Coroner also has discretion to call a jury where she considers there is sufficient reason for doing so. The Coroner may seek the views of Interested Persons before making a decision on whether to exercise her discretion.
Yes. Inquests are open to the public and to the media. Media will have access and will be able to report on the inquest. Those attending the inquest should note that the courtroom is subject to the same restrictions as would apply to normal court proceedings. For further information please see Chief Coroner Guidance No. 25 – Coroners and the media.
Yes. Those attending the inquests should note that the courtroom is subject to the same restrictions as would apply to normal court proceedings.
Transcripts of hearings will be published daily on this website together with, wherever possible, the evidence that has been seen and heard during the course of the inquest.
A coroner is responsible for deciding who should give evidence in an inquest and may seek the views of Interested Persons before making a decision.
A witness may be called to give evidence if they can provide material and relevant information on the issues which fall to be considered.
A coroner has the power to compel witnesses to appear if that becomes necessary and, subject to certain criteria, can read witness evidence.
After hearing the evidence at an inquest into a death, a coroner or jury (if there is one) must make certain determinations and findings (see section 10 of the Coroners and Justice Act 2009 and rule 34 of the Coroners (Inquests) Rules 2013).
A determination needs to record formally the answer to the four statutory questions (the identity of the deceased and where, when and how they came by their death). The findings are the details required for registration purposes. The outcome of an inquest is recorded on a Record of Inquest.
In respect of the question ‘how’ the deceased came by his or her death, the possible short-form conclusions which are available to a coroner or jury may include the following:
These would be recorded in box 4 of the Record of Inquest. As an alternative, or in addition to one of the above ‘short-form’ conclusions, a coroner or jury may make a brief narrative conclusion.
Further details about the outcome of an inquest, including law sheets and guidance, can be found on the website of the Office of the Chief Coroner.
Where a coroner has conducted an inquest, and anything revealed gives rise to concern that circumstances creating a risk of other deaths will occur or continue to exist, then the coroner must report the matter to a person who the coroner believes may have power to take such action.
Examples of this might be reporting matters to a police force, the Crown Prosecution Service or the Health and Safety Executive (this list is not exhaustive).
A person or organisation to whom a coroner makes such a report must give the coroner a written response to it within 56 days, or longer if permitted by the coroner.
An Interested Person is defined in section 47 of the Coroners and Justice Act 2009. A coroner may designate an Interested Person (often shortened to ‘IP’) if they meet the legal test set out in this section.
Examples of those who may be designated as an Interested Person as of right include a parent, spouse or sibling of a deceased person, the beneficiary of a life insurance policy held by the deceased person or a Chief Constable where the death involves a homicide offence. A coroner may also designate any other person whom they consider has a sufficient interest.
Interested Persons are entitled to participate in the inquest. They will receive disclosure of relevant materials from the coroner, they may make legal submissions and are permitted to ask questions of witnesses called to give evidence.
A solicitor to an inquest has a varied role, including:
The role of counsel to an inquest may include: