The Inquest Process

A brief guide to the Inquest process following the opening of the Inquest

The Inquest will be opened and adjourned for investigations to be conducted and reports to be prepared.

The Coroner will review progress in the matter on a regular basis and all interested persons will be informed of decisions made at each review. Reviews are not public hearings and no information arising from them will be made public. They will not be listed on the Coroner's website.

In the first instance the case will be adjourned for a period of six weeks for the first review.

Where applicable the Coroner will have written to the pathologist giving him/her instructions about the retention of any tissue samples that were retained at the post mortem examination.

Usually the post mortem report is delivered to the Coroner within five weeks of the examination itself. However, if complex tests or other investigations are necessary, this may take considerably longer.

Usually the deceased will be released for burial or cremation on the day the post mortem examination is undertaken, but there may be a delay if further tests or examinations are necessary.

The deceased will be released as soon as possible.

When the post mortem report is received the Coroner will consider it and may decide that he is able to conclude the Inquest as a Document based Inquest under Rule 23 of the Coroner's (Inquest) Rules 2013.

The Inquest will not be concluded without consultation with the interested persons.

If the interested persons are content with a documentary Inquest, then the Coroner will fix a date and time for the final hearing which will be listed on the Coroner's website.

The Coroner's Officer for the case will notify all the interested persons of the date and time fixed for the hearing and the Coroner will confirm this to interested persons in writing.

If it is not possible to conclude the Inquest on receipt of the post mortem report because either the Coroner's investigations are not complete or, a full hearing with the attendance of witnesses is necessary, then the Coroner will consider the file and decide what should happen.

If further reviews are necessary the Coroner will, on a regular basis, consider the progress that has been made and will give further directions to ensure that a final hearing, with witnesses being called if necessary, is arranged as quickly as possible.

There are some cases that take a considerable amount of time to enquire into.

All files are monitored regularly to ensure that all appropriate steps are taken and that delays are kept to a minimum. All those properly interested will be notified of the progress of the Coroner's investigations and the steps being taken.

As soon as the Coroner is ready to hear the Inquest the Coroner's Officer will contact the interested persons to notify them of the date and time fixed for the hearing and the listing details will be published on the website.

Pre-Inquest Review

If the Inquest is complex, reports are not forthcoming, or it appears that the adjournment is continuing for too long, the Coroner will fix a date when all interested persons, including the family of the deceased and any legal representatives will be required to attend court for a formal hearing. This will be a public hearing.

At a Pre-Inquest review the Coroner will deal with any outstanding matters and will give such further directions as are necessary to prepare the case for a final hearing.

Usually the Coroner, in conjunction with the family and legal representatives will, at the Pre-Inquest review, decide upon the scope of the Inquest, the evidence to be heard and the witnesses to be called at the final hearing.

The date for the final hearing will usually be set at this Pre-Inquest review. All interested persons will receive written confirmation of the date and the date will be publicised on the website.

Any properly interested person who wishes to inspect or receive copies of any statement or document to be considered at the Inquest may apply to the Coroner.

Final Hearing

This is the resumption of the adjourned Inquest and is a public hearing.

When interested persons arrive at court the will be shown around the court and given an explanation of what is to happen.

Generally all witnesses will be in court during the Inquest.

The family of the deceased and all other properly interested persons will have the opportunity to give evidence and to ask questions of the witnesses who are called.

The Coroner will hear all the evidence and then make the findings of fact that are required; he will announce his conclusion about the death (his 'determination' previously known as the verdict).

On Conclusion of the Inquest

The Coroner will write formally to the family or the executors confirming his determinations, findings and conclusion, and will explain the Registration process.

The Coroner will write to the Pathologist instructing him/her to follow the instructions regarding retained tissue (if any) given by the family when the Inquest was opened.


© 2008 Worcestershire Coroners Service. All rights reserved.