A Brief Introduction to Coroner's Courts

Prepared by Patrick Andrews of Robin Thompson & Partners

The inquests are carried out in the Coroner’s Court. The main function of the Coroner’s Court is to enquire into the death of a person within the Coroner’s jurisdiction, who has:
a) Suffered a violent or unnatural death or;
b) Suffered a sudden death and/or from an unknown cause or;
c) Died in prison.

The purpose of the inquest is to determine how, when and where the deceased died. The inquest is an enquiry into the causes of death. It is not an inquiry to determine blame. This is something that should always be carefully explained to the next of kin and it is always necessary to the advocate appearing on behalf of the next of kin to address their questions towards the issue of causation rather than blameworthiness.
Coroner’s Courts Inquests are inquisitorial, not accusatorial and there are therefore no parties to an inquest. The Coroner plays an inquisitorial; role in that he conducts proceedings and ask most of the questions. He will examine and cross examine all the witnesses under oath. Any lawyers attending on behalf of the estate or any next of kin of the deceased will be given the opportunity of asking the witnesses questions but will be pulled up if their questions turn to deal with the issue of blameworthiness rather than the cause of death.

The Hearing
The Coroner at the inquest usually sits alone although a Jury is required in cases of death occurring in prison or Police custody or where it has resulted from an accident, poisoning or disease, notice of which is required to be given to a Government department.

Juries are also necessary in circumstances, the continuance of possible reoccurrence of which are prejudicial to the health to safety of the public. Unless there is an application for evidence to be heard in camera, i.e. a case involving the security services for example, an inquest takes place in open court. The inquests are often tape recorded and evidence and any arguments are written down.
The usual rules of evidence as regards hearsay do not apply and the coroner has the final say over what questions may or may not be asked. The coroner also determines what witnesses will be called and the order in which they will be called but any party has the right to ask the Coroner to take evidence from witnesses.

The Witnesses
Various types of witnesses are called to give evidence at the inquest. Evidence of identification is required. This is usually provided by a member of the family, it could be the doctor or nurse or someone else that knew the deceased well. The majority of the witnesses will be witnesses as to fact.

The Coroner will usually call witnesses is such order as to give a clear account, in sequence, of the vents leading up to the deceased’s death. Where there is an individual who appears to be responsible for the death, he or she would normally be called last.
The witnesses are sworn or they affirm and they identify themselves. The Coroner will lead the witnesses through their statements previously prepared and provided to the Coroner usually via the Coroners Officer who is usually a Police Officer. The Coroner will usually adduce evidence of the witnesses:-
1) Relationship to or knowledge of the deceased.
2) The events leading up to or including the incident leading to the death.
3) The deceased’s general state of health. This is more likely where the psychiatric nurse will be called to give evidence on behalf of the deceased who may have been a patient.

Once the witnesses give their evidence, usually by being lead through their reports or statements, the Coroner will ask anyone present whether or not they would like to ask he witness questions. The witness will then be cross examined by the advocate with a view to elucidating further information regarding the death.

Medical Evidence
If the psychiatric nurse has actually prepared a report on the deceased rather than just giving factual evidence as regards the manner or domeanour of the deceased, for example in a suicide case the Coroner will call the nurse to give their medical evidence after the evidence of fact has been taken. Although for the purposes of the Court’s convenience and sometimes the convenience of the witnesses, medical experts might be allowed to give their evidence before the evidence as to facts.
The psychiatric nurse may be asked to give professional evidence as regards the deceased’s condition and/or treatment. Basic research into the areas of expertise involve usually assisting cross examination.
If the Coroner calls the psychiatric nurse in their professional capacity once the nurse takes the oath or affirms the Coroner will address them in the following fashion;

Your name is (name) and your address in (address). You are a community psychiatric nurse based at (name of hospital, etc) and on (data) or during (dates) you interviewed and/or examined, counselled or treated (name of the deceased). You now produce Exhibit (previous written report) which is you report on the deceased’s psychiatric condition/treatment.

It is likely that questions will be asked by the psychiatric nurse as regards their evidence by the Coroner and any advocate on behalf of the estate or next of kin.
After considering all the evidence the Judge will sum up. It is in fact quite unusual for the Coroner to sit with a Jury; they usually sit alone. If the Coroner is sitting alone it is not necessary for him to sum up on the evidence although, in practice, the Coroner may refer to it briefly. The Coroner will usually state in public the verdict he has reached.

The Verdict
The conclusion as the cause of death is known colloquially as the verdict whereas, in fact, the whole inquest is “the verdict”. It is usually the most important finding at an inquest. The following standard verdicts are available;
(i) Natural causes
(ii) Industrial disease
(iii) Dependence on drugs non-dependent abuse of drugs
(iv) Want of attention at birth
(v) Killed himself or herself whilst the balance of the mind was disturbed
(vi) Attempted/self induced abortion
(vii) Accident/misadventure
(viii) Execution of sentence of death (very rare these days)
(ix) Killed lawfully
(x) Open verdict
(xi) Killed unlawfully
(xii) Still birth

As regards categories (I) and (iv) above the following words may be added if appropriate “ and that the cause of death was aggravated by a lack of care/self neglect”. An open verdict may be returned where there is insufficient evidence to return any other suggested verdict.