How is a sudden death investigated?

In this blog, Riffat Yaqub, Partner & Catastrophic Injury Solicitor, Hodge Jones & Allen Solicitors, explains the role of inquests when there has been a sudden death.

It is always devastating for families and friends to come to terms with a sudden bereavement, especially when it is not clear what options they have and how the State will address an unexpected death.

When the death is sudden and unexpected, an inquest is usually held where the death was violent or unnatural, when the deceased was in a state detention including prison/police custody or detention under the Mental Health Act, or when the cause of death is still uncertain after a post-mortem.

The purpose of the inquest is to investigate the circumstances surrounding the death conducted by a Coroner. The Coroner’s court is unlike any other civil or criminal court in that its role is limited to the determination of the facts surrounding a death. It is not for the Coroner to seek to apportion any blame. During an inquest, the Coroner will want to investigate the following questions:

•   Who was the deceased?
•   When and where did they die?
•   The medical cause of their death
•   How they came by their death.

The ‘how’ they came to die question is the main focus of the inquest.

When will the inquest be?

The inquest hearing should normally take place within six months or as soon as possible after the death has been reported to the Coroner. If the situation is complicated it can take longer. From my experience, when there has been a sudden and unexpected death, the inquest proceedings will often be adjourned as there will also be a concurrent criminal investigation or a regulatory investigation (for example by the Health and Safety Executive) into the death.

Following a criminal investigation, the Crown Prosecution Service may decide to charge suspects of a criminal offence and bring a prosecution. As such, the inquest proceedings may be put on hold until the conclusion of any criminal court proceedings.

In certain cases, where a sudden death has occurred and a public inquiry has been called, the inquest may be integrated into the inquiry and there will be a dedicated inquest function to the public inquiry’s fact-finding task.  

Prior to the inquest, there may be a Pre-inquest Review (PIR). The purpose of the PIR is to establish the practical steps required to prepare for the inquest. This can include collating evidence and documents which will be relied upon at the inquest. In some cases it is common to have more than one PIR to ensure all interested parties are fully prepared for the inquest.

The first PIR can often be very challenging for family members and friends as it may be the first time that they will be confronted with the procedure to investigate how their loved one died. The PIR hearings are helpful in that they provide families and friends with an insight into how the inquest will prepare and this transparency is really crucial to guiding families and friends through a really challenging process.

Where will the inquest be held?

The inquest is normally heard at the deceased’s local Coroner’s Court. People regularly ask me how long the inquest will actually take. In my experience, it can last a day, a few days or even in some circumstances a number of weeks. The reason for this is that it will depend on the death in question, the issues to be explored and the amount of evidence, which the Coroner’s Court will have to consider.

Who can attend?

Any “Interested person” is entitled to attend the inquest. The Coroners and Justice Act defines an  “Interested person” as a spouse, civil partner, partner, parent, child, brother, sister, grandparent, grandchild, child of a brother or sister, stepfather, stepmother, half-brother or half-sister, a personal representative of the deceased, a medical examiner exercising functions in relation to the death of the deceased, a beneficiary under a policy of insurance issued on the life of the deceased, the insurer who issued such a policy of insurance, a person who may by any act or omission have caused or contributed to the death of the deceased, or whose employee or agent may have done so and others.

An “Interested person” has rights during an inquest; they are provided with copies of relevant documents held by the Coroner including that which the Coroner considers relevant to the inquest. They are also able to see written evidence and have the right to object to it being used as evidence at the inquest hearing and are able to question witnesses giving evidence.

It is possible to have legal representation at an inquest if you feel it would be of some assistance. Given the nature of the hearing, it can be very overwhelming and it is sometimes beneficial for legal representatives to attend with you to ask the questions you want answering.

The Coroner’s Conclusions

Once the Coroner has heard all the evidence they will sum up all that has been heard. The Coroner will then give their conclusion (previously known as the ‘verdict’) and will also complete the Record of Inquest form to note the findings that were reached.

At most inquests there is no jury and the Coroner decides the conclusion on their own. However, sometimes a jury is used when the sudden death has occurred while the deceased has been in state custody or if their death was linked to their own or someone else’s actions while at work, or to certain health and safety issues and if it is in the public interest.

If there are legal representatives present in court, they can make submissions about which conclusions they think the Coroner should consider.

Some conclusions the Coroner may consider include:-

•   Suicide
•   Natural causes
•   Industrial disease
•   Alcohol/drug related
•   Accident or misadventure
•   Lawful killing
•   Unlawful killing
•   Stillbirth
•   Road traffic collision.

A coroner may also reach an open conclusion, where there is not enough evidence to determine the cause of death. A narrative conclusion can also be found, in which the Coroner will set out the circumstances of death in more detail, based on the evidence heard.

The impact of COVID-19 on Inquests

Covid-19 has impacted the operation of Inquest proceedings with some hearings having to be postponed.

Guidance from the Chief Coroner is that all hearings that can possibly take place remotely (via whatever means) should do so. Other hearings should continue only if suitable arrangements can be made to ensure social distancing.

As matters stand, the Chief Coroner’s view is that the Coroner in any hearing (remote or otherwise) will have to be present in court, even if the other parties are not. Coroners are encouraged to make every attempt, where possible, to enable the participation of those involved in the inquest such as the bereaved family. However, as inquests are more reliant on medical expertise than other proceedings, and as Covid-19 is placing substantial strain on our healthcare system, the availability of such expertise to Coroners is likely to cause further delays. Such delays mean that many families will have to wait longer for answers as to how their loved one died, and whether their death could have been prevented. Many still have no idea how long they will have to wait.

It is crucial that all those involved in the inquest proceedings are able to follow the guidance from the Chief Coroner and adapt to remote hearings, where this is possible, to ensure that families and friends are not made to wait indefinitely in seeking answers.