What is an inquest?

When someone dies unexpectedly in medical care, an inquest can provide vital answers. It’s a public legal process designed to investigate the circumstances surrounding a death. For families, it can be an important step in understanding what happened and whether the death could have been avoided.

What is it?

An inquest is a fact-finding inquiry led by a coroner, usually held in a coroner’s court. It aims to determine four key things: who died, when, where, and how. It is not a trial, and doesn’t assign blame or decide on compensation. Instead, it looks at the evidence to establish the facts. Inquests are particularly important in cases where the cause of death is unclear, or when the death was sudden, violent, or took place in state custody. This can include patients under the Mental Health Act or those who died during or following medical treatment.

When does an inquest arise?

A coroner must hold an inquest if someone dies in circumstances that are unnatural, unexplained, or raise public interest. In cases involving medical care, an inquest may be triggered if the death appears unexpected, or if the family raises concerns about how the person was treated.

If there is uncertainty about the cause of death, the coroner may order a post-mortem before deciding whether an inquest is needed. In some cases, the family can ask for an inquest if they believe one is justified and the coroner has not yet opened one.

What does an inquest look into?

The coroner gathers evidence from a range of sources. This may include hospital records, witness statements, expert medical reports, and the results of any post-mortem. If the case is complex, or involves wider issues of public concern, a jury may be called to assist the coroner.

Inquests can also look at the broader circumstances of a death, such as the systems, decisions, or omissions that may have contributed to it. This is often the case when families suspect medical negligence.

What an inquest can and can’t do

An inquest can provide important findings, including whether neglect played a part in the death. However, it cannot determine legal liability or award damages. That means it’s not a substitute for bringing a claim for medical negligence through the civil courts.

Nevertheless, the information revealed during an inquest can often inform any future legal action or formal complaint. The findings can be a powerful tool in helping families seek accountability or changes in practice.

What is ‘neglect’ in an inquest?

It’s important to understand that inquest ‘neglect’ has a specific meaning. It refers to a failure to provide basic care that directly contributed to someone’s death. This could include, for example, failing to monitor a deteriorating patient or not acting on obvious warning signs.

However, a finding of neglect is not the same as negligence in law. Legal negligence usually requires proof that a duty of care was breached and that this caused harm. A coroner does not make that kind of legal judgment.

What happens after an inquest?

Once the inquest concludes, the coroner may issue a report to prevent future deaths, if concerns have been identified. Families may use the findings to bring a civil claim, trigger a regulatory investigation, or request changes to clinical practice.

In some cases, an inquest might mark the end of the process. In others, it may be the starting point for seeking justice or change.

If you would like further information on inquests, please contact our Medical Negligence team on 0330 221 8855 or email enquiries@attwaters.co.uk for a no cost, no obligation discussion.