Inquests in England and Wales are held into sudden or unexplained deaths and also into the circumstances of and discovery of a certain class of valuable artefacts known as "treasure trove". In England and Wales, inquests are the responsibility of a coroner, who operates under the jurisdiction of the Coroners and Justice Act 2009. In some circumstances where an inquest cannot view or hear all the evidence, it may be suspended and a public inquiry held with the consent of the Home Secretary.
There is a general duty upon every person to report a death to the coroner if an inquest is likely to be required. However, this duty is largely unenforceable in practice and the duty falls on the responsible registrar. The registrar must report a death where: [1]
The coroner must hold an inquest where the death is: [2]
Where the cause of death is unknown, the coroner may order a post mortem examination in order to determine whether the death was violent. If the death is found to be non-violent, an inquest is unnecessary. [2]
In 2004 in England and Wales, there were 514,000 deaths of which 225,500 were referred to the coroner. Of those, 115,800 resulted in post-mortem examinations and there were 28,300 inquests, 570 with a jury. [3] In 2014 the Royal College of Pathologists claimed that up to 10,000 deaths a year recorded as being from natural causes should have been investigated by inquests. They were particularly concerned about people whose death occurred as a result of medical errors. "We believe a medical examiner would have been alerted to what was going on in Mid-Staffordshire long before this long list of avoidable deaths reached the total it did," said Archie Prentice, the pathologists' president. [4]
A coroner must summon a jury for an inquest if the death was not a result of natural causes and occurred when the deceased was in state custody (for example in prison, police custody, or whilst detained under the Mental Health Act 1983); or if it was the result of an act or omission of a police officer; or if it was a result of a notifiable accident, poisoning or disease. [5] The senior coroner can also call a jury at his or her own discretion. This discretion has been heavily litigated in light of the Human Rights Act 1998, which means that juries are required now in a broader range of situations than expressly required by statute.
The purpose of the inquest is to answer four questions: [6] [7] [8] : r. 36
Evidence must be solely for the purpose of answering these questions and no other evidence is admitted. [7] It is not for the inquest to ascertain "how the deceased died" or "in what broad circumstances", but "how the deceased came by his death", a more limited question. [7] Moreover, it is not the purpose of the inquest to determine, or appear to determine, criminal or civil liability, to apportion guilt or attribute blame. [8] : r. 42 For example, where a prisoner hanged himself in a cell, he came by his death by hanging and it was not the role of the inquest to enquire into the broader circumstances such as the alleged neglect of the prison authorities that might have contributed to his state of mind or given him the opportunity. [7] However, the inquest should set out as many of the facts as the public interest requires. [9]
Under the terms of article 2 of the European Convention of Human Rights, governments are required to "establish a framework of laws, precautions, procedures and means of enforcement which will, to the greatest extent reasonably practicable, protect life". The European Court of Human Rights has interpreted this as mandating independent official investigation of any death where public servants may be implicated. Since the Human Rights Act 1998 came into force, in those cases alone, the inquest is now to consider the broader question "by what means and in what circumstances". [10]
In disasters, such as the 1987 King's Cross fire, a single inquest may be held into several deaths. Some inquests, such as the John Lawler inquest, result in a prevention of future deaths report. [11] [12]
Inquests are governed by the Coroners Rules. [8] [13] [14] The coroner gives notice to near relatives, those entitled to examine witnesses and those whose conduct is likely to be scrutinised. [15] Inquests are held in public except where there are real issues and substantial of national security but only the portions which relate to national security will be held behind closed doors. [8] : r. 17
Individuals with an interest in the proceedings, such as relatives of the deceased, individuals appearing as witnesses, and organisations or individuals who may face some responsibility in the death of the individual, may be represented by a legal professional be that a solicitor or barrister at the discretion of the coroner. [8] : r. 20 Witnesses may be compelled to testify subject to the privilege against self-incrimination. [8] : r. 22
If there are matters of national security or matters which relate to sensitive matters then under Schedule 1 of the Coroners and Justice Act 2009 an inquest may be suspended and replaced by a public inquiry under s.2 of the Inquiries Act 2005. This can only be ordered by the Home Secretary and must be announced to Parliament with the coroner in charge being informed and the next of kin being informed. The next of kin and coroner can appeal the decision of the Home Secretary.
The following conclusions (formerly called verdicts) are not mandatory but are strongly recommended: [16]
In 2004, 37% of inquests recorded an outcome of death by accident / misadventure, 21% by natural causes, 13% suicide, 10% open verdicts, and 19% other outcomes. [3]
Since 2004 it has been possible for the coroner to record a narrative verdict, recording the circumstances of a death without apportioning blame or liability. Since 2009, other possible verdicts have included "alcohol/drug related death" and "road traffic collision". [17] The civil standard of proof, on the balance of probabilities, is used for all conclusions. [17] The standard of proof for suicide and unlawful killing changed in 2018 from beyond all reasonable doubt to the balance of probabilities following a case in the courts of appeal. [17]
Owing in particular to the failures to notice the serial murder committed by Harold Shipman, the Coroners and Justice Act 2009 modernised the system with:
A coroner is a government or judicial official who is empowered to conduct or order an inquest into the manner or cause of death. The official may also investigate or confirm the identity of an unknown person who has been found dead within the coroner's jurisdiction.
Felo de se was a concept applied against the personal estates (assets) of adults who ended their own lives. Early English common law, among others, by this concept considered suicide a crime—a person found guilty of it, though dead, would ordinarily see penalties including forfeiture of property to the monarch and a shameful burial. Beginning in the seventeenth century precedent and coroners' custom gradually deemed suicide temporary insanity—court-pronounced conviction and penalty to heirs were gradually phased out.
A fatal accident inquiry (FAI) is a Scottish judicial process which investigates and determines the circumstances of some deaths occurring in Scotland. Until 2009, they did not apply to any deaths occurring in other jurisdictions, when the Coroners and Justice Act 2009 extended the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 to service personnel at the discretion of the Chief Coroner or the Secretary of State. The equivalent process in England and Wales is an inquest. A major review of the fatal accident inquiries was undertaken by Lord Cullen of Whitekirk, at the request of the Scottish Government, which resulted in the passing of the Inquiries into Fatal Accidents and Sudden Deaths etc. (Scotland) Act 2016.
Murder is an offence under the common law legal system of England and Wales. It is considered the most serious form of homicide, in which one person kills another with the intention to unlawfully cause either death or serious injury. The element of intentionality was originally termed malice aforethought, although it required neither malice nor premeditation. Baker states that many killings done with a high degree of subjective recklessness were treated as murder from the 12th century right through until the 1974 decision in DPP v Hyam.
In the English law of homicide, manslaughter is a less serious offence than murder, the differential being between levels of fault based on the mens rea or by reason of a partial defence. In England and Wales, a common practice is to prefer a charge of murder, with the judge or defence able to introduce manslaughter as an option. The jury then decides whether the defendant is guilty or not guilty of either murder or manslaughter. On conviction for manslaughter, sentencing is at the judge's discretion, whereas a sentence of life imprisonment is mandatory on conviction for murder. Manslaughter may be either voluntary or involuntary, depending on whether the accused has the required mens rea for murder.
In English law, Irish law and Northern Irish law, unlawful killing is a verdict that can be returned by an inquest in England and Wales and Ireland when someone has been killed by one or more unknown persons. The verdict means that the killing was done without lawful excuse and in breach of criminal law. This includes murder, manslaughter, infanticide and causing death by dangerous driving. A verdict of unlawful killing generally leads to a police investigation, with the aim of gathering sufficient evidence to identify, charge and prosecute those responsible.
The open verdict is an option open to a coroner's jury at an inquest in the legal system of England and Wales. The verdict means the jury confirms the death is suspicious, but is unable to reach any other verdicts open to them. Mortality studies consider it likely that the majority of open verdicts are recorded in cases of suicide where the intent of the deceased could not be proved, although the verdict is recorded in many other circumstances.
Operation Paget was the British Metropolitan Police inquiry established in 2004 to investigate the conspiracy theories about the death of Diana, Princess of Wales in a car crash in Paris in 1997. The inquiry's first report with the findings of the criminal investigation was published in 2006. The inquiry was wound up following the conclusion of the British inquest in 2008, in which a jury delivered its verdict of an "unlawful killing" due to the "gross negligence" of both the driver of Diana's car and the pursuing paparazzi.
A coroner's jury is a body convened to assist a coroner in an inquest, that is, in determining the identity of a deceased person and the cause of death. The laws on its role and function vary by jurisdiction.
The Coroner's Court of the Australian Capital Territory is a court which has exclusive jurisdiction over the remains of a person and the power to make findings in respect of the cause of death of a person or fire in Australian Capital Territory.
In the legal jurisdiction of England and Wales, there is a long tradition of jury trial that has evolved over centuries. Under present-day practice, juries are generally summoned for criminal trials in the Crown Court where the offence is an indictable offence or an offence triable either way. All common law civil cases were tried by jury until the introduction of juryless trials in the new county courts in 1846, and thereafter the use of juries in civil cases steadily declined. Liability to be called upon for jury service is covered by the Juries Act 1974.
An inquest is a judicial inquiry in common law jurisdictions, particularly one held to determine the cause of a person's death. Conducted by a judge, jury, or government official, an inquest may or may not require an autopsy carried out by a coroner or medical examiner. Generally, inquests are conducted only when deaths are sudden or unexplained. An inquest may be called at the behest of a coroner, judge, prosecutor, or, in some jurisdictions, upon a formal request from the public. A coroner's jury may be convened to assist in this type of proceeding. Inquest can also mean such a jury and the result of such an investigation. In general usage, inquest is also used to mean any investigation or inquiry.
The Infanticide Act 1938 is an Act of the Parliament of the United Kingdom. It creates the offence of infanticide for England and Wales.
Gunasegaran Rajasundram was a Royal Malaysian Police detainee who died in the police lock-up while under arrest for suspicion of drug possession. Coincidentally, his death was on the same day as Teoh Beng Hock's body was found. The case of R. Gunasegaran is crucial to the discussion on police practices because it highlights several issues with the policing of Malaysia: the safety of whistleblowers, human rights during police custody, the procedures of inquests, and the practices of the police force. Understanding this case could bring us to find out what more could be done to better the policing system of Malaysia.
Paul Knapman DL was Her Majesty's coroner for Westminster, from 1980 to 2011. His responsibility for investigating sudden deaths as an independent judicial officer saw him preside over numerous notable cases.
The Ashley Smith inquest was an Ontario coroner's inquest into the death of Ashley Smith, an aboriginal teenager who died by self-inflicted strangulation on 19 October 2007 while under suicide watch in custody at the Grand Valley Institution for Women. Despite guards watching her on video monitors, Smith was able to strangle herself with a strip of cloth, and it was 45 minutes before guards or supervisors entered her cell and confirmed her death. The warden and deputy warden were fired after the incident; although the four guards and supervisors in immediate contact with Smith were initially charged with negligent homicide, those charges were withdrawn a year later. Smith's family brought a lawsuit against the Correctional Service of Canada (CSC) for negligence; this lawsuit was settled out of court in May 2011.
In many legal jurisdictions, the manner of death is a determination, typically made by the coroner, medical examiner, police, or similar officials, and recorded as a vital statistic. Within the United States and the United Kingdom, a distinction is made between the cause of death, which is a specific disease or injury, versus manner of death, which is primarily a legal determination, versus the mechanism of death, which does not explain why the person died or the underlying cause of death and can include cardiac arrest or exsanguination.
The Deaths at Deepcut Barracks is a series of incidents that took place involving the deaths in obscure circumstances of five British Army trainee soldiers at the Princess Royal Barracks, Deepcut in the county of Surrey, between 1995 and 2002.
Inquest Charitable Trust is a charity concerned with state related deaths in England and Wales. It was founded in 1981. Inquest provides support on state-related deaths, including deaths in custody and their investigation, to bereaved people, lawyers, advice and support agencies, the media and parliamentarians.
Athelstan Braxton Hicks was a coroner in London and Surrey for two decades at the end of the 19th century. He was given the nickname "The Children's Coroner" for his conscientiousness in investigating the suspicious deaths of children, and especially baby farming and the dangers of child life insurance. He would later publish a study on infanticide.