How to report on an inquest in England and Wales

INQUEST REPORTING: FAQs

The type of inquests we’re concerned with here are the court proceedings that come at the end of an investigation into an unnatural or suspicious death. This process is presided over by a coroner with a support team including at least one court clerk. The rules and guidance governing inquests are complex, here we provide a simple guide for people interested in turning up and observing court proceedings.

What is the purpose of an inquest?

Inquests are legal inquiries into the causes and circumstances of a death. They answer four key questions:

who died,
where they died,
when they died,
and how they came to their death.

It’s within a coroner’s power to expand the question of “how a person came by their death” by asking in addition:

by what means and in what circumstances a person came by their death.

You might hear this type of investigation referred to as an Article 2 inquest or a “Middleton” inquest (by what means and in what circumstances) or “Jamieson” inquest (by what means).

Which deaths have an inquest?

Inquests are opened when there’s reasonable suspicion a death was violent or unnatural; where the cause of death is unknown; where the person died in custody or otherwise in state detention; when the Chief Coroner directs that there should be an investigation. See Coroners and Justice Act (2009) for more on the duties of a coroner.

What is an Article Two inquest?

Article 2 of the European Convention on Human Rights, the right to life, imposes a duty on the state to protect life. It also requires the state to carry out an effective investigation into a death, involving the family of the deceased, these are known as Article 2 inquests.

An Article 2 inquest has more scope for the coroner or jury to leave critical conclusions on what has happened. Deaths of someone in state detention, such as in prison or policy custody, or a person held under section in psychiatric care, are Article 2 inquests.

Which inquests have a jury?

Inquests must be held without a jury unless the coroner suspects:

the person died in prison, police custody or otherwise in state detention and the death was violent, unnatural or cause unknown;
the death resulted from the action or omission of a police officer in the purported execution of their duty;
the death was caused by a notifiable accident, poisoning or disease;
the death occurred in circumstances where the continuance or reoccurrence of these circumstances is prejudicial to public health and safety.

A coroner also has discretion to hold an inquest with a jury if they think there is sufficient reason to do so.

What is a ‘Jamieson’ and a ‘Middleton’ inquest?

Jamieson and Middleton refer to case law and both types consider neglect. Jamieson inquests consider whether a lack of care, or common law neglect, has led to the cause of death. Usually heard where death occurred in a medical context or where someone was in police or other custody immediately prior to their death (including death by suicide).

Middleton inquests relate to state involvement in a death. In the Middleton case a jury considered an agent of the State (the Prison Service) had failed in its duty of care to the deceased, who hanged himself in prison while identified as at risk, however proper safeguards weren’t put in place.

Attending an inquest

What’s a senior coroner, area coroner and assistant coroner?

There are 92 coronial jurisdictions, each with a senior coroner appointed by the local authority in which they sit. The senior coroner is in charge of their area and they work alongside full-time employed area coroners and part-time assistant coroners.

Some coroners are medical professionals but the Coroners and Justice Act 2009 states that all newly appointed coroners must be qualified lawyers (solicitors, barristers or legal executives with at least five years’ experience).

What is a coroner’s officer, a listings officer and a court clerk?

A coroner’s officer assists the coroner and serves as liaison between them and bereaved families, they are often retired police officers. Listings officers organise the court diary and court clerks are officers of the court who provide administrative support to the court.

How can I find out about upcoming inquests?

Coroners must give advance warning of inquests, that does require you to check each coroner’s website for information. You can call the coroner’s office phone number, which is usually listed on the website.

What are PIRs, or pre-inquest reviews/hearings?

A coroner will often hold at least one and often several pre-inquest reviews or pre-inquest review hearings in complex cases. These are held to assist with inquest preparation. There are no set agendas or procedures for the hearing, but they are held in open court, in the same manner as an inquest. Interested persons attend and may contribute to the discussion.

Are inquests always held in public?

Yes, unless there are exceptional circumstances, usually matters of national security. Public hearings allow members of the public and journalists to attend. Some parts or sections of the inquest could be held in private, if national security would be compromised by the information being in the public domain.

What are the rules around reporting from inquests?

The Chief Coroner has shared guidance for coroners on engaging with the media (Guidance No25). This guidance makes it clear that the starting premise is one of Open Justice:

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