Guidance: A guide to Coroner's inquests in drowning cases

GUIDANCE

A short guide to Coroner's inquests when investigating drowning cases in commercial and non-commercial settings in England and Wales. 

Who are Coroners? 

A coroner is an independent judicial office holder appointed by a local authority within the coroner’s area. They are usually lawyers but sometimes doctors.

What do Coroners do? 

They investigate deaths that have been reported to them where the death was violent or unnatural, the cause of death is unknown or where they died in prison, police custody, or immigration centre.

Coroners establish who has died, how and when they died, and other information to allow the deceased family to register the death.

Are all deaths reported to a Coroner? 

No. Deaths are reported to the coroner where any of the following apply:

• The cause of death is unknown,
• The death occurred at work,
• The death was sudden and unexplained,
• The death was in suspicious circumstances.

Who reports a death to the Coroner? 

Anyone can report a death to the coroner. If a doctor is able to confirm the medical cause of death, then typically, a coroner is not required.

What happens once a death is reported to the Coroner? 

A coroner will decide if an investigation is required. If it isn't required, they will release the body to the family for the funeral to take place. They may order a post-mortem to assist their decision as to whether an investigation is required. They will also be in communication with the relevant investigatory authorities about any investigation or charging decision they are considering, as this will affect how the coroner proceeds. 

What happens following the coroner's initial investigation? 

The coroner will hold an inquest if any of the following apply: 

• if the cause of death remains unclear 
• they suspect the deceased died of violent or unnatural causes
• or the death occurred in custody or state detention 

What happens if a person is charged with an offence in relation to death?

The coroner will normally pause their investigation to allow the criminal process to conclude before reviewing whether an inquest will be required. 

If you are a suspect or potential suspect in relation to a criminal investigation, you would be advised to seek advice and/or representation from a solicitor for the inquest; particularly if other parties are also represented by a solicitor or barrister. Legal aid may be available if the inquest is complex or there is a very real possibility of a custodial sentence in your criminal trial. Legal aid is subject to affordability checks. 

You may represent yourself, and the coroner will assist you with the process. 

How long will I have to wait before the inquest takes place? 

Inquests will typically be heard in 6 months. Regulatory criminal investigations involving workplace deaths are increasingly complex and protracted. Inquests in such cases may take place several years after the death. In one case we covered on this blog, it was six years later. 

How does a coroner open an inquest? 

The coroner must formally open an inquest as soon as it is determined that it is required. An inquest must be opened in a short public hearing which will be adjourned to allow evidence to be collected.

The coroner may hold a pre-inquest review or directions hearing to determine the scope of the inquest where circumstances are complex. This is an important hearing for a pool operator as the inquest will later be held in public and has been known to influence the decision of subsequent investigatory bodies in their decision to charge a defendant. It is not unusual for an operator to be represented by senior counsel in serious cases. 

Families or their representatives will have the opportunity to raise questions or issues which they feel the coroner should include within the scope of the inquest. Members of the public and press can present unless the coroner directs otherwise. 

What is the purpose of an inquest? 

An inquest is a public hearing held to determine the cause of death of the deceased for the purpose of enabling the family of the deceased to obtain an accurate death certificate. An inquest is not about establishing liability or blame. 

Is there a jury? 

Most inquests are held without a jury. The notable exception to that is if the death occurred in custody or state detention or it resulted from an accident at work. In those cases, the coroner will decide the law and procedure elements, and the jury will make determinations and findings as to the cause of death. There will be between seven and eleven members of a coronial jury.

Do you have to attend if called to give evidence? 

It is the coroner’s decision who should be called to give evidence and the order they give their evidence. Parties can make representations to the coroner to include additional witnesses. It is a criminal offence if you fail to attend when summoned by the coroner to court on the date(s) of the inquest, punishable by a fine or imprisonment. 

What questions will I be asked? 

Witnesses may be called to give evidence under oath, and you may be asked questions by party representatives or the coroner. The coroner will always ask their questions first, and then the party representatives will be given time to ask theirs.

Questions that attempt to purport blame are not permitted in these hearings, and the coroner will ask the representative to rephrase the question or disregard the witness's answer. Establishing the cause of death is the only concern. 

What does the jury decide? 

The jury does not establish liability or blame. They can state facts that, to the average observer, indicate the jurors' view that the death was caused by factors such as neglect. 

What does the coroner determine? 

A coroner will determine the cause of death. Where a jury is present, the coroner may expand on the facts and give reasons for the determination.

What is a Prevention of Future Deaths (PFD) notice? 

Where evidence heard at the inquest may have the capability to prevent future deaths, the coroner has the power to issue a Regulation 28 (PFD) notice. 

The notice is addressed to parties that the coroner believes have the power to take action to prevent similar deaths in the future. An organization that receives a PFD notice has 56 days to respond to the notice. 

The coroner may send the notice and any letter or response from the interested parties to the Chief Coroner, who may subsequently decide to publish the notice and response in the public domain via the Judicial Office website (see http://www.judiciary.gov.uk). 

Is the inquest paused where a civil claim is pending? 

No, although the normal process is that a civil claim follows the conclusion of the inquest.   

Why has the coroner ordered a second post-mortem? 

A second post-mortem will be issued where it may assist the coroner in determining the cause of death. 

Can I appeal a determination or decision of the coroner? 

Yes, in certain circumstances. You should first raise your concern with the coroner. If you remain unsatisfied, you may complain to the Judicial Conduct Investigations Office. You may also complain to the local authority who is responsible for the coronial service.

You should seek legal advice if you have serious concerns. You have up to 3 months following the coroner's decision or determination to issue judicial review proceedings in the High Court. If your concern relates to a decision of the coroner prior to final determination, you should seek legal advice immediately and not wait until the inquest's conclusion. 

If the issue is of general public importance, you may make representations to the Office of the Attorney General. 

If you wish to complain about the conduct of a pathologist, you should make this complaint to the General Medical Council. 

Citation: Jacklin, D. 2021. A short guide to coronial inquests in drowning cases. Water Incident Research Hub, 24th August.