Photo from internet


Inquests - what you need to know


"Opening an inquest" and the venue

Inquests relating to industrial deaths are often "opened" (in practice mentioned in the Coroner's Court) shortly after the death and the substantive hearing will take place at a later date (sometimes some months later).

As the Coroner (referred in Court as "Sir" or "Madam") may have no permanently allocated court building inquests may be heard locally to where the deceased lived more often than not at a Magistrates Court or sometimes Town Hall or other Council owned building.

Purpose of the Inquest and Coronial law

The Coroners Court and process is by way of investigation and is not adversarial as in the civil courts. The Coroner may call to give evidence whosoever can provide evidence to assist in reaching a verdict. The family may also call their own witnesses but only with permission of the Coroner. The Coroner is said very much to "run his/her own show". Coronial law is very different to civil law and is set out in The Coroners' Act 1988 and Coroners' Rules 1994. Coroners are qualified as either lawyers or doctors. The Coroner does not investigate blame or any civil damages claim issue as the Coroner's task is solely to ascertain "why, when and how" the deceased died.

In addition we now have the Coroners and Justice Act 2009.
http://www.justice.gov.uk/publications/coroners-justice-bill.htm

Key changes include a national coronial service rather than locally based and the appointment of a new chief coroner advising other coroners and reporting to government. The previously complex appeals process should also be improved.

The Coroners' rules prevent the Coroner from apportioning blame for the death. However a Coroner or jury may add a rider to their verdict. Thus such issues as damages and who is to blame are left to the High Court or County Court to resolve. The Human Rights Act and the European Convention have had a significant impact on the way certain inquests are conducted in the UK.

What happens after the death and why there is an inquest

The Coroner must be informed when someone dies unexpectedly and for a suspected asbestos related industrial disease death it is compulsory that an inquest be heard. Such verdicts inform national statistics as to the number of industrial deaths and are collated. The Registrar of Deaths is also obliged to notify the Coroner and indeed any other person (including a doctor) if aware of such circumstances requiring an inquest to be held have a legal duty to inform the Coroner. For an industrial disease related death such as caused by asbestos exposure (mesothelioma) the inquest will not involve a jury and the hearing will usually take well under half an hour unless exceptional. The Coroner may call to give oral evidence the pathologist who carried out the post mortem and provided a report. Usually that evidence is given by the reading of a witness statement pursuant to Rule 37 of the Coroners Act. The Coroner also may call a member of the family to give evidence as to the background to the deceased's asbestos exposure. In most cases solicitors acting for the family are able to send to the Coroner a copy of the deceased's own witness statement and medico legal report prepared during the deceased's lifetime as this will undoubtedly provide helpful evidence for the Coroner. This may mean that a member of the family is not called to give evidence. Giving such evidence may well be most upsetting, particularly for the widow, and is then hopefully avoided.

"Paper only" inquests

A recent development for mesothelioma death inquests may result in H M Coroner dealing with the inquest by way of a "paper only" hearing without need of attendance of the family or other witnesses. The verdict is made upon the available written evidence only. Many families prefer this so as not to have to attend a formal hearing.

Industrial death verdicts

The Coroner then gives his judgment and the verdict is usually one of mesothelioma and industrial death caused by asbestos exposure or something similar. Some asbestos related deaths can be primarily caused by the disease mesothelioma (Part A1. ) of verdict but the actual death be a complication of the illness (Part 1B. of the verdict. Or vice versa. After the verdict the case is concluded and invariably the Coroner's Officer explains to the family how to apply for a final death certificate. The family maybe asked if tissue slides are to be retained for a period of time or indefinitely or if not required (for the civil action) may be destroyed or returned to the family [see below]. The Coroner may decide (if it is not proven that the death was caused by asbestos exposure) that the death was due to "natural causes" in which case a death certificate will be issued and there will be no inquest. 

Post-Mortem

The post-mortem will be carried out at the Coroner's request by a pathologist shortly after the death. Relatives are entitled to be represented by a medical practitioner at the post mortem or to have a second post-mortem carried out by their own pathologist (but this rarely is necessary). Once a post-mortem has been carried out the funeral can take place. The Coroner will study the post-mortem report and unless he is satisfied that the death was by natural causes he will usually proceed to hold an inquest.

Lung samples /asbestos fibre counts

As part of the post mortem lung tissue/slides are usually taken for analysis by microscopic examination (histology). Invariably asbestos fibres are found that assist in confirming a mesothelioma/lung cancer. However if exposure was "light" during the deceased's employment fibres may not be found. Also the slides/tissue will only contain a minute part of the lung tissue and fibres and may therefore be missed in the sample taken. This may lead to some further questioning usually undertaken by the Coroner but may need further clarification by the family's lawyers. Interpretation of lung tissue results may well be an important reason why a lawyer rather than the family alone should attend the inquest.

It is crucial for a post mortem to be carried out and lung samples taken and retained particularly where lung cancer is believed to have been caused by prior asbestos exposure. A claim was recently struck out as an abuse of process in the QBD (High Court) where tissue samples were disposed of by the family. [Snr Master. QBD. Weaver and Gurney v Contract Services 29 6 2010].

Who can participate?

The inquest is held in public and anyone can attend, although parts of the inquest can be held in private ("in camera"). Interested parties (usually the family) can attend and question the witnesses and make submissions to the Coroner. Although inquests are less formal than normal Court proceedings they can be emotional and many families find it easier if someone who is not emotionally involved can speak on their behalf. Sometimes a defendant (who may later be sued or is being sued in a civil claim for damages) may attend the inquest usually by lawyers. The Coroner generally invites the family to ask any questions so that nothing is missed.

Funding and recoverable costs for inquest representation

Reasonable and proportionate legal costs of attending an inquest are usually recoverable from the Defendant as part of a civil Court damages claim [The Bowbelle (1997) 2 Lloyds Rep. 196]. Stewart and Howard v Medway NHS Trust 6 4 2004) and the Porton Down inquest].

There remains some limited provision for funding from the Lord Chancellor's Department (now MoJ) for representation at an inquest but only for exceptional cases such as the Ronald Maddison death at Porton Down in 1953 and new inquest ie matters of "Wider Significant Public Interest".

In a recent Court decision on recoverable inquest costs [Roach v Home Office, Matthews v Home Office 2009 EWHC QB] the Home Office argued that inquest costs should not be recovered. 50% were allowed on appeal. Mr Justice Davis approved "Bowbelle" (The Marchioness disaster) and allowed the Inquest costs "in principle".

It has been said that one has to be as "poor as a church mouse" to qualify for public funding and would not usually be available for industrial death inquests. Also see the Legal Services Commission website :
http://www.legalservices.gov.uk/docs/cls_main/Funding_Code_chp27_Exceptional_Funding.pdf

Legal expense insurers (see for example any Home Contents policy "legal expenses") may also be prepared to fund the inquest if there is cover in the policy for personal injury and death, particularly if a damages claim for compensation is likely to follow.

Not an asbestos death inquest but providing some guidance is: Courtney v Our Lady's Hospital Ltd MLC 1802 (Ireland High Court, O'Neill J, M! ay 27, 2011) Damages: Nervous shock. The parent of a child who had died in circumstances which were not adequately explained to the satisfaction of that parent would have a vital interest in establishing the true facts concerning how the death had occurred. The plaintiff had a liability to her legal representatives in respect of their reasonable costs in providing legal representation at the inquest

You should not have to attend the inquest on your own

For the majority of inquests involving an industrial cause a lawyer will attend with you and provide legal representation as it is important to any future claim for compensation and part of the evidence gathering. If necessary Counsel may be instructed to appear. But usually only if there are complex legal or factual issues or perhaps if your solicitors are not locally based. So you should not have to attend on your own.

Disclosure of Evidence

The Coroner will usually (if requested) supply interested persons (or their lawyers) with a copy of the post-mortem report and any documents put into evidence at the inquest, but these documents only have to be disclosed at the inquest. In practice most Coroners will release the post-mortem report and witness statements to the family of/or  deceased's legal representative in advance of the inquest. The formal "Inquisition" document may be obtained from H M Coroner. A type written transcript of the hearing may also be obtained after the hearing (as most hearings are now tape recorded) at a fairly nominal cost for the transcription.

What to do after a suspected asbestos related death

You will usually be contacted by the Coroner's Officer. You should inform your lawyer as soon as possible of who the Coroner is and his/her address and telephone number.  Contact with the Coroner will be made by the lawyers to make the appropriate representations for you.

Why is it so important to have an inquest?

An inquest verdict of industrial death will assist you when bringing a claim for damages. Although the High Court and County Court may come to a different decision the Coroner's Court verdict is highly persuasive and is rarely changed or challenged in the civil courts. It is also vitally important that all deaths caused by industrial disease are recorded so that action may be taken to prevent further deaths; compiling of national statistics and informing government policy. For the family an inquest may well help and be seen as drawing a line under a loved one's death by way of judicial scrutiny.

 David Masters. H M Coroner, Wiltshire. Photo from internet.

In the wider context Rule 43 of the Coroners Rules 1984 has been amended (17 July 2008):

Coroners have a wider remit to make reports to prevent future deaths. It does not have to be a similar death.
A person who receives a report must send the coroner a written response.
Coroners must provide interested persons to the inquest and the Lord Chancellor with a copy of the report and the response.
Coroners may send a copy of the report and the response to any other person or organisation with an interest.
The Lord Chancellor may publish the report and response, or a summary of them.
The Lord Chancellor may send a copy of the report and the response to any other person or organisation with an interest.
http://www.justice.gov.uk/guidance/docs/coroners-reports-future-deaths.pdf 
This power is sometimes used by Coroners to draw attention to important issues of concern that require resolution by government/regulatory authorities and others. Such inquests usually receive much media attention. 

Last updated August 2010 

Published 2011 "Inquests" John Cooper QC. Hart Publishing.

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