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Inquest Procedure

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iloveglee | 21:21 Fri 10th Nov 2023 | Law
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Is anyone able to give me any information about an inquest procedure.  I know is it not adversarial as in a court case, but just to establish who died, where and when they died and how.  But not why.  And to give a cause of death. 

Background for the query.  Some very good friends/family have lost their daughter/sister in very tragic circumstances.  There was an overdose of drug/s involved, and only one person was present at the time of what led to the death and that was her partner. There had been previous serious mental health issues with the deceased, and therefore this could be a case of suicide.   The partner who was present is seen by the family as a bad person and a liar, is will therefore not be believed.  

The family have asked my husband to be the person to ask questions as none of them feel able to do this.  As such I am  intending to be present also, but neither of us has ever been to an inquest so really dont know what to expect.  

Is the normal process that anyone who has been interviewed, which will be the partner, paramedics, hospital staff,  friends and family, work colleagues, will be called to give evidence in person, or would it be just that their statements are read out.  Will the family have access to these statements prior to the hearing, so that they can work out questions they may want to ask in advance.  

It is a pretty complex case and we are fairly sure there will be a large bundle of documents, not least interview/s by the police of the partner, as he was known previously to them for domestic abuse and drug taking, if not dealing.  The family know from previous incidents he was a very controlling if not abuse person to their daughter, but they were not able to persuade her to sever contact with him.  The inquest is set for mid december, so it is being assumed that no criminal action is being taken against the partner, so there is no suspicion that he is responsible for the death.  I know that the inquest is not there to determine responsibility for the death.  

I'd be very grateful for any information at all that anyone can offer.  




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I am also interested in this as we are awaiting an inquest for a cousin who died apparently of a drug overdose in suspicious circumstances.

A bit heavy for Ab, but I expect Newjudge and Barmaid will be along soon to help, so I'll bump it.

no-one HAS to ask questions.

when i attended my daughter's inquest, the facts were presented by the police.

we were asked a few questions by the coroner.

we did ask a question because the night she died, the road to the hospital was closed and the ambulance had to do a lengthy detour because they didnt know it was closed.  We asked the coroner to ask the ambulance service and highways agency wat their procedures were for disseminating the info aout closed roads so it didnt happen again


ps i didnt answer your other q.

we asked for the bundle of documents and got them many weeks before the inquest, which allowed us to seek legal advice first, in the end, after speaking with our solicitor team and a barrister, we decided for no legal representation

we asked for photos to be redactd, so we didnt have to turn over a page and be confronted by awful photos, and they were redacted.

The coroners office staff were incredibly helpful and kept us up to date wit things.  Our inquest was opened and adjourned for over a year

i also warn you that press may be present



Question Author

Thanks very much for the responses, especially for the link, this document is very helpful and instructive.  There are now not many weeks to the inquest, which is due on 18th December, so the family need to get on with requesting the documents.

As my husband is the one designated to ask questions, should there be any, he really needs to have time to go through them, and see which ones are relevent to what the family may wish to ask.  The medical ones will be very hard to understand, so as someone with a little bit of medical background, I might be able to help.  I don't think though that they will wish to ask anything around the hospital care, but as one of the drugs she had taken was illegal, they will certainly want to ask, if they are able to, how she was able to access these.  Even though, actually they know who supplied them to her, and i think they haven't quite grasped the concepts of inquisitorial as opposed to adversarial, hence this person will not be cross examined by anyone.  It's going to be hard for them, as we both know the questions they want answered, are probably not going to be answered.  

From reading the document from the link, I imagine that witnesses will probably be called to give their account, rather than it just being a statement reading exercise.

At this stage they have a date for this, but am not aware they have been given any indication as to how long it is likely to take. 

We know, and I hope that the family, who are all planning to be there, will know that this is a public hearing, not just them but the whole court will hear what we fear is going to turn out to be quite a sordid story.  We know also that the press will be there, and no doubt it will be reported in the local press.  The one saving grace for them is that she kept her married name, even after being divorced, so no link will be made to their name in the media.  The parents are thankfully not on social media so they will be spared that.  

Anything further anyone has to add will be very much appreciated. 

A bit heavy for Ab, but I expect Newjudge....will be along soon to help, so I'll bump it.

Sorry. Know next to nothing about inquest procedures.

no-one HAS to ask questions.

no one has the DUTY to ask questions - see above. no one has the RIGHT to ask questions - they are properly put thro the coroner

and he can say - I am not gonna ask that.... 

whittington before the reforms was very good - "do you have all the answers you want?" -to th relatives

but of course other coroners may not do that


"What will happen first?

Where an inquest is needed, the coroner must ‘open’ it as soon as possible. The hearing to open the inquest is usually very brief and will be held in public. This means that members of the public may attend and in some cases the press may also attend and report details. Usually, the coroner will then immediately adjourn or pause the inquest until a later date when they have all the information they need to resume the inquest hearing. For example, the coroner may decide expert reports are needed to help understand what contributed to the death. At the opening of the inquest, the coroner must set the dates of later hearings where possible. For some inquests, however, where all the information is available already, the inquest can be opened and the coroner will hear the inquest and make conclusions in that hearing. The coroner’s office will tell you if this is the case. You do not need to attend the opening of the inquest but if you want to do so, you should tell the coroner’s office so that they can tell you when and where it will take place."


Has the family been given any indication as to what will happen in December?

no I  think that is why she is asking  ( italic not intended).

I was principal witness in a case of run-over child which I scraped off the motorway. It IS pretty harrowing. a 12 year old failed to appear as a witness and the coroner threatened to send out a policeman to arrest him....

Question Author

From the circumstances surrounding the death, i.e. cardiac arrest secondary to having taken medication and ? an illegal drug, and only one person (who is not to be trusted) present, there are going to be many and varied expert witnesses I am certain.

I am pretty certain there is going to be the documentary evidence from the 999 call, the paramedics, the A&E staff, the ITU staff, along with many and varied lab reports.  She had interaction with the crisis mental health term about 5 months prior to her death, so a report from them as well.  Her GP I guess.  Friends we know have been interviewed about her state of mind at the time of her death, her employer, and the most important witness the so called partner who was there at the time.  

So I have no doubt there will be quite a bundle of documents.  From the link I as was so kindly supplied with on here, my understanding is that these documents are supplied to 'interested parties' of whom I expect are her family.  Nothing has been received as yet.  The document led me to believe they are automatically supplied prior to the inquest, but doesn't give much idea as to how long prior to the inquest.  In order to know whether their questions are answered in this bundle of documents, they'll probably need to have some time to process it. 

So currently they are at the stage where there is a date set, they only just received the post mortem report a few weeks ago, which does show an illegal drug, as well as a prescription drug  in her blood on arrival at the hospital, but as to whether these drugs either singly or in combination  were  the cause of, or just implicated in her death they don't know.  

So my husband is going to be the person who will ask questions, if in fact if there are questions still to be answered from the documentary evidence.  What we don't know, and maybe someone on here does, do the questions you want to ask have to be run by the coroner prior to the day, I do know some questions are neither relevant to this procedure nor probably would they be admissable.  Better to get the yes or no before the day i would have thought, if in fact this is how it works.  



we had very good communication with the coroner's office (and the police in fact) and it was thru them we arranged to receive the documents.  how would the court know who was an interested party unless they were told?

Question Author

The family did have very good communication with the coroner initially, and the police officer attached to them.  This is where they were told they would be able to have a copy of all the evidence, statements, etc. and assumed that they would receive it automatically.  Theyve not had any communication recently, and haven't yet received any documents.  So now theyre wondering do they have to apply for them.  We are not aware, and neither were they, how long in advance they would receive them.  

So the coroner knows that the family, the father of the deceased who is leading this process on their behalf, are interested parties.  Also, which adds to the complication, he is not next of kin, and has no responsibility for any of the complicated issues that arise from that.  The deceased person had a son, who is under the age of 18, the father from whom she was divorced has parental responsibility and he has taken over all of the probate applications, sorting everything out in the house, her car, everything, against the wishes of the other members of her family.  Relations with him werent good in the first place, now they are worse, and what they don't know is whether he has been in touch with the coroner himself and requested this bundle of documents.

My husband has advised that he needs to contact the coroner asap, not to wait any longer, and see exactly what's happening.  It's a very sad and difficult situation for all of them, and at times it seems that they're floundering a bit.  We know they want answers to exactly what and how this happened, but they may never know.  

i was just looking back over the notes i made at the time. 

The police also told us in advance what they thought the likely verdict would be (and they were right)

i seem to have a note that they have to give the bundle out at the latest 2 weeks before the inquest, but i remember having it way before then probably about 6 weeks.  However, that may have been due to individual circumstances i guess

Question Author

To bedknobs - when you received your bundle of documents, did these arrive automatically, or did you have to request them.  Our friend has not received them yet, its 4 weeks to the inquest.  He has apparently tried to make contact with them, without success.  They haven't had any contact with the coroners office, or the police officer assigned, for several weeks now.  They just had a phone call with some information as to what the death was caused by, i.e. misuse of two different drugs.  They weren't sure if this was this was going to form the verdict or not.   They didn't say accidental death, or suicide as a result of this misuse, which is what we believed the coroner was to determine.

We know, and I believe they are beginning to realise is that the question they want answered, which is, did the partner she was with introduce her to drugs, and as such led to her death.  This doesn't seem relevant to me, everybody who knows her knows it was him that introduced her to them, but the police aren't taking him to court for anything, and  the inquest isn't there to determine blame.    

I really hope for their sake that when the documents come, questions they may have will be answered in them, but the answer they so badly want, i.e. who is to blame, will not be answered there.  After all, their daughter was a competent, consenting adult, and even if she would have never come into contact with drugs  but for him, he didn't force them down her throat, or up her nose.   Everybody also knows he was coercive and controlling, but again the police must believe there is insufficent evidence to get him into court for this.  They truly believe he is to blame and is going to get away with it.  Sadly, I think theyre right. 

we asked for them, but we had a good contact at the coroner's office who also liaised with the police.  it may be because she was a child, rather than an adult though.

I did most of my liaising with the coroner's office by email.  I just looked back at the emails and actually i think the bundle may have come from the police.  There ws no jury, and a single witness (police officer)  i did note this in one of the emails from the coroner's office though: "It is helpful if you can submit questions in advance, as I would like to ensure we are able to answer your questions."

i would try to contact both the officer in the case and the coroner's office if i were you

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