What is a coroner's inquest for?
An inquest is a public court hearing investigating a death. Its purpose is narrow and specific, and misunderstanding that narrowness causes considerable distress to families expecting something else.
The four questions an inquest answers, and only these:
Who the deceased was.
When they died.
Where they died.
How they came by their death.
It is a fact-finding inquiry, not a trial. It is inquisitorial — the coroner conducts the investigation and calls the witnesses — with no prosecution, no defence and no parties in opposition.
Critically, an inquest cannot determine criminal or civil liability, and coroners are prohibited from framing findings in a way that appears to do so. It cannot find someone guilty, award compensation, or apportion blame between individuals. Families frequently hope for accountability the process is expressly forbidden from delivering.
When an inquest is held. A coroner must investigate where a death was violent or unnatural, where the cause is unknown, or where the person died in custody or state detention — including prison, police custody and detention under the Mental Health Act.
Conclusions may include natural causes, accident or misadventure, suicide, unlawful or lawful killing, industrial disease, drug-related, or an open conclusion where evidence is insufficient. A narrative conclusion sets out the circumstances in the coroner's own words and is increasingly used because it can capture complexity a short label cannot.
Standard of proof. Suicide and unlawful killing were historically found to the criminal standard; following the Supreme Court decision in Maughan (2020), the civil standard — balance of probabilities — applies to suicide.
Article 2 inquests are broader, engaged where the state may have failed in its duty to protect life, and examine the wider circumstances rather than only the immediate cause. Deaths in custody typically fall here.
Juries are required in specific circumstances, including some deaths in custody.
Prevention of Future Deaths reports are issued where a coroner identifies a continuing risk.