What happens at an inquest?

[Bearfrills]

Long story short, my dad died last year and we've been waiting for an inquest date. The coroner is satisfied with the cause of death but has multiple questions about the chain of events surrounding it, clinical decision-making processes, and any impact of delays.

We got the evidence bundle through for a Pre-inquest review hearing and, based on that, have asked for an independent specialist to review some of the medical information as there is professional disagreement in the statements given by the two lead consultants who cared for him (basically one of the says Y should have happened and the other says no, X was the correct action and even if Y was done wouldn't have changed the outcome anyway).

It says we can cross-examine witnesses on the day, how would that work? I feel like I'd be completely out of my depth doing that. Or do I send the coroner our questions in advance and they can ask them? Or do we not need to ask anything at all? Is it like a proper court hearing like they'd have at a criminal hearing? How formal is it? I know these are silly questions, I'm just trying to prepare as much as possible.

You can ask the witnesses questions. I lost my blob with one of them because she sat and lied and got shushed by the coroner. Not my finest moment but lying in coroner's court is outrageous.

They're very nice and will help you with anything you need. Go through the evidence and make notes of things that stand out to you. You don't have to ask anything if you don't want but you may find you have a question or 2.

There is a service that goes through inquest reports for you but I can't remember who they were. I got the name from the CAB.

The meeting before the inquest was just to meet the coroner and staff. What room you'll be sat in and where the jury will sit if any. They'll go through everything with you and you can ask anything you need there

Don't worry, they're so efficient and professional and totally try to put you at ease.

I'm sorry you are having to go through an inquest, they are protracted and prevents a person from moving on/grieving properly imho.

My experience of an inquest happened during COVID, so might be a bit different in terms of set up but key details probably the same. The inquest I attended was for my mum who died unexpectedly in hospital due to a complication from a relatively routine procedure she had.

Anyway, it was all conducted online with a video feed. Doctors who attended my mum's care, plus coroner etc were all there, including any additional witnesses. I received a pack of documents about 6 months ahead of inquest which I could review, including hospital notes, witness statements conducted by coroner etc, plus autopsy details. I didn't end up getting an independent review of the docs because I didn't feel it necessary, but reading through it, I had my own questions. It was quite informal in that after listening to the events and reports, and account of doctors, I had the opportunity to ask my questions. You can also question things throughout if necessary.

Once the coroner was satisfied there were no more questions, they decide on official cause of death for the final death certificate. And that's it really.

It was pretty straightforward but it ended up taking so long (18 months after my mum's death) due to the pandemic. I can't say I ever want to attend another one again. You should have contact with the corner through an assistant who you can communicate with if you have any questions beforehand.

Hope that helps. Hopefully someone with in-person experience might be able to shed some light on if the process is different.

I'm sorry for your loss.

Hello. I have worked in this area of law.

It is a court hearing in a court room but usually less formal than a criminal court.

The coroner asks questions of the witness first. You might find a lot if not all of your questions will be answered by the coroner.

Then you can ask questions, then any representative from the hospital trust.

You can send questions in advance but you dont need to. You can ask them on the day. The coroner should support you to understand your concerns and help you ask questions in a structured way.

After the evidence the coroner will take a break to answer the questions the law requires them to which are who the deceased was, where they died, when they died and how they came about their death. They dont make civil or criminal liability findings but they can make factual findings about what is more likely than not to have happened if care was different.

And independent expert is helpful as they will have no siding with anyone and should offer some objective info.

I cant give legal advice but might be able to help with questions about the process if you have any.

In general I suggest:

Dress smartly but comfortably. It is court but you dont want to be squirming in too tight clothes.

There will be toilets/water/tissues but often not much else so think about taking snacks or medicines you may need in the day

If more than one family member is going try to nominate one as spokesperson as it makes it easier and stops talking over each other.

Its a lot to take in on the day but it is recorded and you can ask for a recording afterwards.

Hope that helps and so sorry for your loss.

How much you say or if you wish to speak at all, or even attend is your choice. You are allowed to ask questions so you can prepare by writing down ahead of time things that you want to explain, want to query or are confused about for example. You may also find you want to question something that’s said on the day, or clarify something. If it’s too much you can leave the room. It may be useful to have a trusted family member or friend who can read out things for you if you find it difficult to do yourself. It’s not a trial, it’s a fact finding process, and it will be due to contradictions, confusion or unexpected outcomes/chain of events and not necessarily because anything is actually wrong, also it’s to learn from situations. Thinking of you it’s a difficult situation. I’ve supported several people through this process and it’s actually been different each time because each was different circumstances

Thank you all, some really helpful information here.

It's definitely stopping me from being able to move on properly, or being as moved on as I could be. It's like it's not finished yet because there's still this one last process to sort out so I can deal with my feelings yet.

How strict is the coroner on shushing? One of my siblings is adamant they want this person sacked and that person sued. He's been told that this isn't what the process is about, he's just grieving and looking for someone to blame. I don't think he'll say anything on the day but I need to give him a talking to about what'll happen if he doesn't behave.

My experience @Bearfrills is that the coroner is very much in charge. They give a lot of space for families but they will be very clear what questions they will allow, what they won't and sticking to the remit of the inquest, which is actually very limited.

The one for my mum took almost two years due to delays getting information from the drug company of the drug that caused her death. I can't remember much about it except the drug company representative offering his condolences and being questioned. I'm sorry you are having to go through this it is horrible and as others have said prevents/ delays moving on. I don't think any of us family members asked questions , we probably should have done. Lots of changes relating to the drug that killed her have since taken place and I don't see it prescribed half as much now as it was back then for the condition my mum had so I do hope some good came out of the inquest to stop the same thing happening to others. .

Every Coroner is different in terms of tolerance for comments over questions. Some will allow a lot of leeway for family to explain how they feel others will be stricter to relevant questions.

If your sibling says that so and so should be sacked they will probably be reminded that isnt what an inquest is for and if they continue then any coroner will become more stern.

My best advice is to go with an open mind. That's the best way to take what you can from the process. Anyone who goes with a fixed view that y or x would have resulted in z is likely to be disappointed.

And remember its all new to you but the coroner does it every day. Its their job to ensure you can participate properly.

Coroners are very good with an icy patience. It's all about sticking to facts. Your relative won't have any options but to behave.

As for suing. That's all on your own time and there's no point in bringing it up. I think your relative will see that and I really hope you all get some satisfaction.

Inquests are horrible. They interrupt the grieving process in ways you don't realise. Even though the jury found hospital in question had missed opportunities and changes were to be put in place in the NHS I didn't feel the need to sue afterwards. I sent a message to the coroner saying it has been an honour to watch him work, in a I wish I hadn't met him kind of way. They're very good at their job

I hope you all find some peace when it's over.