Do I need a lawyer? Expand We would always recommend that you have legal representation where possible, especially if you have concerns about the circumstances of your loved one’s death. Many families tell us that having a lawyer helped them to: - Understand and navigate the inquest and any investigation processes; - Liaise with the coroner about things such as upcoming hearing dates; - Understand and manage disclosure (documents relevant to the inquest, such as medical notes); - Obtain documents, such as investigation reports; - Make submissions and applications, and question witnesses in court; - Feel that they were supported through the inquest process. It is also important to remember that other Interested Persons involved in the inquest, such as prisons, hospital trusts or police forces, will have their own lawyers (and sometimes several).
How do I find a lawyer? Expand We would always recommend finding a lawyer with specific inquest experience, as most solicitors do not have expertise in inquest preparation and some may give you inadequate advice or charge very high fees. Legal funding for inquests is also complicated, so it is important that your solicitor knows how to help you get the limited funding that may be available. INQUEST works with a network of lawyers across the country (the INQUEST Lawyers Group) who have specialist inquest experience. They also usually only represent bereaved families in the inquest process (rather than the state). Contact your INQUEST caseworker if you would like us to refer you to an appropriate lawyer. If you would prefer to find your own lawyer, the websites at the bottom of this factsheet may help. You must feel free to ask them questions about their experience and how much they know about the different processes. We would also suggest that you put your lawyer in touch with us, so that we can provide your lawyer with additional advice, information and support throughout the process. Traditionally a solicitor advises you and prepares for the inquest, and then instructs a barrister to represent you at court. However, some ‘solicitor-advocates’ are qualified to represent people at hearings. It is also now possible to instruct a barrister directly (provided that they are ‘direct-access qualified’) to represent you at the inquest hearing, without first instructing a solicitor. This can be a useful option if you are not eligible for public funding, or if you are having difficulty finding a solicitor who is able to take on your case. If you are considering this option, we would suggest that you speak to an INQUEST caseworker first.
How do I pay for legal representation? Expand Legal aid Unfortunately, there is no automatic public funding for a family’s legal costs at an inquest. However, public funding, or ‘legal aid’, might be available depending on your financial circumstances and the particular nature of your loved one’s death. You might be eligible for legal aid if: - You fall within the financial threshold set by the Legal Aid Agency. - and the inquest falls into certain categories. This will usually be: Cases which engage Article 2 of the European Convention on Human Rights (the ‘right to life’). Article 2 will often apply to deaths which took place whilst the deceased was in the care or custody of the state, such as - whilst in prison; - whilst in police custody or following police contact; - whilst detained under the Mental Health Act 1983; or - whilst subject to an order depriving them of their liberty. Cases which the coroner decides arguably engage Article 2; and A very rare category of cases which are considered to engage issues in the ‘wider public interest’, such as disasters. However, it is important to understand that Article 2 depends on the particular circumstances and will not always apply in the categories above, for example, it may be more difficult to get funding if your loved one died from ‘natural causes’. If you are not sure whether your loved one’s inquest will fall within this category, speak to your INQUEST caseworker. Even if you fall above the financial threshold set by the Legal Aid Agency, you may still be eligible for legal aid if the inquest engages Article 2. However, you may also be required to make some contributions towards the cost. You should speak to your INQUEST caseworker if you are not sure whether you will be eligible for legal aid. You should be aware that applying for funding is complex, and the forms you will need to fill in are very detailed and can be intrusive and stressful. Often each family member will need to provide the Legal Aid Agency with very detailed information about their financial affairs. Your solicitor should be able to guide you through the process and respond to any queries you may have. In some cases coroners may be willing to write a letter in support of a funding application. This will assist with the funding application, but does not necessarily mean that funding will be granted. If you are not eligible for legal aid, depending on your circumstances, it might be possible to fund your legal representation in other ways: ‘Conditional Fee Agreements’ (also called ‘no win, no fee’) This might be possible if you are also pursuing a civil claim (such as a clinical negligence claim) on your loved one’s behalf. The inquest costs would then be covered by a successful civil claim (but you would not be asked to pay if your civil claim was unsuccessful). Your lawyer should explain your legal costs and funding options very carefully to you. If you are in any doubt, make sure to get a second opinion or speak to your INQUEST caseworker. Legal Expenses Insurance Your home and motor insurance or trade union membership may cover the cost of inquest proceedings, however this is very rare. You would also need to check your policy very carefully to find out exactly what type of representation it might cover. If your loved one was a member of a trade union, the union may provide you with free legal representation at the inquest and help you in any claim for compensation. ‘Pro bono’ help Sometimes it’s possible for us to find a lawyer who might be able to represent you for free. Your INQUEST caseworker will be able to tell you whether this might be possible. Crowdfunding Crowdfunding using platforms such as CrowdJustice can sometimes be successful when traditional forms of funding representation aren’t possible, such as where you would like to re-open an inquest but aren’t eligible for legal aid. Paying yourself It is important to know that inquests can cost thousands of pounds, so you must think very carefully before deciding to pay privately. We would advise you to speak to your INQUEST caseworker first.
The purpose of a Pre-Inquest Review Expand A pre-inquest review or hearing (PIR or PIRH) is an administrative hearing that is typically held where an inquest is complex or involve a number of interested persons. All interested persons or their representatives will be usually be present. The coroner will make decisions about the practical arrangements of the inquest (see below). The hearing may last for a hour or so, but could be longer.You are allowed to attend these hearings.
Before the Pre Inquest Review Expand The coroner should have given you an agenda when they informed you of the date and time that the pre inquest review (PIR) would be held. This should let you know what will be discussed. If they haven’t the coroner should go through an agenda right at the beginning of the PIR. If you arrive a bit earlier than the start time, you should ask the coroner’s officer if you can have a look at the court, so you can familiarise yourself with the room and where everyone will be sat. If the PIR is going to be held remotely, make sure you have received a link to join the hearing. This will usually be given to you by the coroner's officer.Bring any notes you have made so far with you, including the questions or concerns you have given to the coroner, if you have a copy.
Things the coroner might consider at the Pre Inquest Review Expand Below is a general list of all the matters that will be considered or decided during a PIRH Interested PersonsIf this hasn’t been decided already, the coroner will note who all the interested persons are and identify any other potential interested persons.Article 2 The coroner should confirm whether Article 2 of the European Convention of Human Rights (the right to life) is engaged. They will also decide if a jury is required for the final inquest. JuryThe coroner will decide if a jury is necessary for the final inquest. The function of the jury is to reach a finding of fact having heard all the evidence. Scope of the inquestThe coroner should provide you with their initial view of any issues they have identified so far. This will be a starting point for how wide of a scope the inquest will have, what information they are considering and if they require further information from any of the interested persons, or other agencies which may be involved. DisclosureThis is any evidence which the coroner receives which is relevant to the inquest. You are an interested person which gives you the right to have sight of disclosure. Some of it may have been shared with you in advance of the PIR. The coroner will also set deadlines for any outstanding documentation to be received by the coroner’s office. You can ask the coroner when you can expect disclosure to be shared with you if it hasn’t been already. WitnessesAs with the scope of the inquest, the coroner will provide you with a provisional list of witnesses that they intend to call to give evidence in person and witnesses whose evidence will be read/ summarised by the coroner. If there is anyone that you would prefer to give evidence in person, make this known to the coroner. The coroner does have quite a wide discretion to decide on witnesses but there is no harm in making your views known. ExpertsThe coroner may decide that an independent expert is needed to assist them with particular points of evidence. You can instruct an independent expert, but this is subject to funding. You can also make representations to the coroner if you think an independent expert is necessary. As with witnesses, the coroner has a wide discretion. If possible, ask for a copy of the letter of instruction, this is the letter which the coroner will send to the expert asking for their services and giving them terms of reference. Dates and timesThe coroner will establish when the final inquest hearing will be and/ or if any further pre-inquest reviews are necessary. They will note when it will be held, where it will be held (if a different location to the ordinary coroner’s court) and how long for.
What is an adjournment? Expand An ‘adjournment’ is when the Pre-Inquest Review Hearing or final inquest hearing is postponed until another date. It is up to the coroner’s discretion whether or not to adjourn, and the coroner will also decide when to resume the inquest again. Generally, coroners prefer not to adjourn if possible as they have a legal duty to consider the impact of delays on their duty to investigate how the deceased died. However, sometimes circumstances mean that it is reasonable for the coroner to adjourn for the inquest to run properly.
Why might I need to request an adjournment? Expand The coroner might decide themselves that an adjournment is necessary, or one of the Interested Persons in the inquest might request an adjournment. There are several reasons why an inquest might be adjourned, such as: You haven’t had enough time to instruct lawyer and get legal advice; You haven’t had enough time to apply for legal aid funding; You haven’t yet received important disclosure (such as investigation reports, hospital records or CCTV); The coroner decides that they need to call certain witnesses or request an expert; The coroner decides that some further investigations or enquiries need to be carried out; You need to submit further written evidence and the coroner agrees it is necessary; or You want to make submissions to the coroner on the scope of the inquest.
How should I request an adjournment? Expand You can either ask your solicitor to make an application or, if you don’t have a solicitor, you can make an application yourself. Generally it is better to request an adjournment as soon as you realise it might be necessary. To request an adjournment yourself, you should put your request in writing directly to the Coroner. However, we would advise that you discuss this with your INQUEST caseworker first. Your caseworker will be able to advise you on the process, and may be able to help you draft the request. To write your request, we have provided a suggested template below: Address your letter to ‘HM Coroner [name]’ and begin with ‘Dear [Sir/Madam]’. Start by setting out why you are writing, for example: ‘I am writing to kindly request an adjournment of the [Pre-inquest Review Hearing] currently listed for [date of hearing].’ Include a brief summary of what happened to your loved one. Clearly set out your reasons for requesting an adjournment. For example: ‘We have reviewed the documents we have been provided with and we would like to seek specialist legal advice on the issues.’ ‘We have not yet received the [PPO report/SIR report/IOPC report/other relevant documentation] and we would like to review this before we can outline our concerns to the coroner. Thank the coroner and sign-off your letter, for example: ‘We sincerely hope you will agree that an adjournment is necessary in the circumstances. We are very grateful for giving this matter your attention. Thank you for your time and anticipated assistance.’
What happens next? Expand The coroner will consider your request for an adjournment and inform you whether they intend to adjourn. If the coroner decides that an adjournment is necessary, the coroner must inform the next of kin or personal representative of the deceased and any other Interested Persons:That the inquest has been adjourned;When the inquest was adjourned;Why the inquest has been adjourned; andWhen and where the inquest will resume again.
How do I draft my witness statement? Expand As a family member of somebody who has died, you may be asked by the coroner to provide a witness statement. When a coroner asks someone to make a statement usually they are trying to establish the factual background that led to a death, information about that person’s care and any concerns that the family may have.Even if you have not been asked, you may want to give a statement so the coroner is aware of the concerns you have and questions you want answered at the inquest.
What do I include in my witness statement? Expand Your statement can cover whatever information you think the coroner should know when making their investigations into how your loved one died. However, it can be very helpful for the coroner to know: 1. Who you are and how you are related to the person who has died 2. Who the person is that has died The coroner is likely to have basic information about your family member from medical records or prison records. It can be important to write a paragraph about who they were, what their family was like, their personality and their hobbies. 3. What you know or remember about the circumstances of their death If your loved one died whilst in custody or detained in a hospital, you may only be able to talk about any communication you had with them by phone or when visiting. However, if they were living at home, you may be able to give a more detailed factual chronology as you remember it of the days, weeks or months leading up to the person’s death. The best way to approach this bit of the statement is often chronologically, writing what you remember. If someone else has told you information you want to include, you can include this as well, but it is always best to say “I was told by……” so that it is clear the information you have got from someone else. 4. What your concerns are An important part of the statement will be to set out the questions you or your family have about the death and any concerns about the treatment your loved one received prior to their death.
Do I have to read my witness statement out in court? Expand In many cases a family member will wish to read out a statement rather than have a lawyer do so but some families will find this difficult and ask their lawyer or the coroner to do it for them.
What is a Pen Portrait Expand A pen portrait is a way to commemorate a loved one who has died. It can help humanise the inquest, putting the family and their loved one at the heart of the process. In most inquests, if you have written a statement then it is unlikely you will also need to write a pen portrait.If the family have not written a statement, they are encouraged to ask that the coroner introduce a pen portrait at the inquest. A pen portrait will help the coroner (and jury) to know something of your loved one – what they did, their interests and hobbies and details of their circle of family and friends. You can also ask to show a photograph of your loved one.At the moment there is no Guidance from the Chief Coroner on pen portraits, which means coroners aren’t obliged to accept them at an inquest. Families are encouraged to ask the coroner at any pre-inquest review hearings if they wish to submit a pen portrait but it will be for the coroner to decide if and when is to be shown or read.
Can I request my relative’s medical records? Expand Accessing medical records is not always straight forward. Under the Access to Health Records Act (1990) only certain people have the right to access medical records of someone who has died: The personal representative of the person who has died. If your relative had a will than the executor of the will be the personal representative. If there is no will, then you will have to apply to the Administrator. Information about how to do this can be found here. Once you have a Grant of Letters of Administration you do not need to provide any reasons for requesting records. This is the most practical way of accessing them. Anyone who may have a claim resulting from the person’s death can also apply to access medical records. If you do not want to bring claim or do not want to be involved in a legal process such as a medical negligence claim they may deny you access to your relative’s medical records.
Who do you apply to for medical records? Expand Primary CareWhen someone dies their GP records will be passed on to the Primary Care Support England to be stored. To request them you should write to the Practice Manager of your relative’s surgery. The Practice Manager will be able to tell you where they are stored. To request NHS hospital records, you can apply to the Access to Medical Records Team at the Hospital which your relative attended. If the records were updated during the 40 days before the date of your application, you should be given access within 21 days. Otherwise the time limit is 40 days. Some people experience difficulties in trying to access their loved one's medical records and it can sometimes be complicated. If you have approached the primary care provider, it may be helpful to tell them the reason why you are asking for the medical records, particularly if is because you might have a civil claim arising from your loved ones death.Trust InvestigatorIf your relative’s death is investigated by the trust, you can also contact the investigator directly and asking for copies of records they have considered as part of their investigation. The coronerAnother alternative is to try is to request the relevant medical records via the Coroner, explaining why you think they will be relevant to the inquest.
The purpose of an NHS Trust's investigation Expand What is a Serious incident Report?The NHS trust who was responsible for your loved one’s care might undertake an investigation into the events surrounding your loved one’s death. This is often called a 'Serious Incident Review' or a 'Root Cause Analysis investigation report'.The purpose of the investigationThe purpose of these investigations is to establish the originating (or ‘root’) causes which are likely to have led to a death. The focus of the investigation will be on establishing any causes and contributory factors to a death, and identifying what lessons can be learned from them. The Trust's report should address: - Establishing what happened - Looking at the standards of care and whether there are any concerns in the standard of treatment or care received - Addressing the family's concerns about care and treatment It is worth noting that often the investigations are often not independent as they are carried out by the same Trust who provided care to your loved one.
Meeting with the Trust Investigator Expand I have been contacted by the trust investigator and asked to meet with them. Do I need to go?You may sometimes be called to meet with the Trust to set out your concerns. You do not have to meet with them if you prefer not to. You could also ask for the information in writing first and then meet them, or you can wait until they have finished their investigation. However, sometimes these meetings can be helpful to find out some details of what happened directly from the care providers at an early stage, rather than waiting for the inquest and investigations to complete.
I've decided I’d like to meet with the Trust Investigator, is there anything I should do beforehand? Expand It would be helpful if you can find out the following: Details of who will be conducting the investigation: their names; their background; their role in the Trust; whether there is any degree of independence (ie. what connection they have with the service etc.); and their experience/expertise in conducting investigations. What the 'terms of reference' for the investigation will be. This sets the scope and areas to be covered by the investigation. What the trust knows about the circumstances so far. It is usually best to ask for this in writing. The trust’s timeframe for conducting the investigation, and whether you will receive a draft of the report before it is finalised. Who you should contact for questions and information sharing through the investigation process. How and when they intend to keep you updated. Confirmation that they will fully disclose to you all relevant records and documents i.e. all evidence they will use to write the final report. You may also want to ask them about their internal processes for organisational responses and learning. How do they approach learning lessons? How does learning get shared? At what stages does this happen? Other things to consider You may also want to share any information you think may be relevant, and to raise any questions and concerns you have. You should be given more opportunities to feed into the process once you receive more information, but unfortunately this does not always happen as it should. Some face to face meetings are more difficult now due to Covid-19, but it may be worth asking if a face to face meeting is possible. This can help overcome the tendencies towards a more remote, paper-based approach. Lastly, always try to bring a friend or someone who can take notes, as these meetings can be really emotional. You can also ask if you can record the meeting. The investigators will be used to such requests and will often agree to this.
What kind of questions should I ask them about what happened to my loved one? Expand Families want to understand exactly what happened to their loved one and how they died. You might have questions which are unique to you and the circumstances. Here are some general questions you may wish to ask to help you to understand the circumstances of your loved ones’ death: When did my loved one die? How did they die? Who was with them when they died/who found them? Was the death unexpected/unexplained? Could the death have been prevented? Were there any actions anyone could have taken, or would have been expected to have taken, to prevent their death?
I do not wish to meet with the Trust Investigator Expand If you do not feel able to meet the investigators face to face, you can either keep the communication strictly to emails and letters, or you can refuse to meet them, especially if you're planning to seek legal representation. It is not unusual for families to reject meetings with trust investigators, as it is difficult to sometimes face representatives from the trust, who you might be holding responsible for your loved ones death. You should not feel under any obligation to meet them, but please bear in mind that sometimes these investigation meetings can be helpful as they can give us some information about the circumstances, and their initial findings, which you may not be able to get otherwise.
If the healthcare provider is not investigating the death of my loved one, what can I do? Expand You can bring a complaint within 12 months of your loved one’s death. This needs to be done in writing to the Chief Executive of the Trust. You can find out the details of the Chief Executive from the trust’s own website.To do this, set out the issues you want to complain about in one or two pages. The Trust will then be obliged to investigate your complaint and tell you about their findings.It would be helpful to copy the Coroner into the complaint so that he or she is also aware of the issues you have raised with the trust.
What is an inquest conclusion? Expand Once a Coroner or jury have heard and considered all the evidence at an inquest, they will give a conclusion as to how someone has died. There are different types of conclusions a Coroner or jury can give
Short form conclusions Expand The Coroner or jury may give a short form conclusion, which is a finding of one or two words, such as: - Natural causes - Accident or Misadventure- Unlawful or Lawful killing - Alcohol or Drugs - related- Suicide- Industrial Disease- Road Traffic Collision- Open – meaning there is not enough evidence to decide how someone died.