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Hospital Deaths, the Role of the Coroner and Inquests

We are often approached by families following the death of a family member in hospital.  It is a difficult time for all concerned. 

Before a death can be formally registered a Doctor will need to issue a Medical Certificate giving the cause of death.  If the death occurs in hospital this is usually done by a hospital Doctor who will hand the Certificate to the next of kin in a sealed envelope addressed to the Registrar of Births, Deaths and Marriages, together with a Notice explaining how to register the death.  The Doctor may not always be able to issue a Medical Certificate of the cause of death and there may be a number of reasons for this. 

 Post Mortem

If a Medical Certificate is not capable of being issued the matter will be referred on to the Coroner, who may order a Post Mortem examination.     

If after the Post Mortem the death was found to be due to natural causes no inquest is required.  If the Coroner establishes however that the death was not due to natural causes then he is obliged to hold an inquest.


An inquest is a medical/legal enquiry into the death of the deceased. It is not a trial.  Often an inquest will be opened and then adjourned to allow a funeral to take place.  Rule 36 of the Coroner's Rules 1984 specifies the matters to be ascertained at inquest .Neither the Coroner nor the jury shall express any opinion on any other matters.

Further Rule 42 states that: "No verdict shall be framed in such a way as to appear to determine any question of criminal liability on the part of a named person or civil liability".

In preparation for the inquest the Coroner will gather information and will make further enquiries of any clinicians involved in the care of the deceased, the family and the Police. 

Once a decision has been made that an inquest is to take place the Coroner must then consider questions as to whether a jury is required to hear the Inquest.

 Article 2 - The Right to Life

Article 2 of the European Convention of Human Rights (the Right to Life) should then be considered.  Article 2 becomes important in cases involving deaths in hospitals, as whilst the European Convention of Human Rights does not include an express right to medical treatment there could be circumstances where the failure to provide such treatment, or the withdrawal of services, could amount to a breach of the Right to Life (Article 2). 

Health Authorities, Special Authorities, NHS Trusts, Regulatory bodies and Local Authorities all have a duty as public bodies to comply with the provisions of the convention and it may be arguable that G.P.s should be considered to be public bodies when treating NHS patients.

The issues surrounding Article 2 are complex and many families who are considering a claim for clinical negligence may ask the Coroner for guidance as to whether it needs to be considered. 

Who Attends the Inquest?

Assuming an inquest goes ahead, Rule 20 of the Coroner's Rules 1984 defines the groups of people who are allowed participatory rights.  They would include parents, children, spouses, personal representatives and beneficiaries under an insurance policy, insurers, "any person whose act or omission... may in the opinion of the Coroner have caused or contributed to the death of the deceased" trade unions and any other regulatory authorities such as the Health & Safety Executive, Chief Officer of Police and any other person who in the opinion of a Coroner is a properly interested person. 

Such properly interested persons have a right to examine any witness at an inquest.

Hearing and Outcome

At the hearing, the Coroner will call the evidence that he feels might help him come to a decision.  He will question witnesses and properly interested persons will have the right to raise questions of the witnesses.  The Coroner will not however allow questions to be raised which might touch on issues of civil or criminal liability.  

Once the Coroner has heard all of the evidence the parties can make submissions without addressing the Coroner or the jury as to the facts.  The Coroner will then come to a verdict.  The Coroner will in essence answer the questions to be found in Rule 36(1) of the 1984 Coroner's Rules namely:

  1. The name of the deceased
  2. The injury which caused death
  3. The time, place and circumstances in which the injury was sustained
  4. The conclusion as to the death
  5. The particulars required by the Registrar of Births and Death

Conclusion/ Verdict of the Inquest

Over the years terms have developed to describe verdicts, such as accident/misadventure, natural causes, unlawful killing or an open verdict.  However increasingly, especially in medical cases, Coroners are departing from the usual wording and creating what are known as narrative verdicts, which are short descriptions of the issues and the findings of fact upon them.  However, as indicated earlier the inquest must not identify either criminal or civil liability at all.  However the Coroner can make a finding of neglect. 

The finding of neglect has a very specific meaning within the Coroner's Rules and case law has assisted in providing a further definition.  In the case of  R -v- North Humberside Coroner Ex party Jamieson, neglect was described as "a gross failure to provide adequate nourishment or liquid or provide or procure basic medical attention or shelter or warmth for someone in a dependant position (because of youth, age, illness or incarceration) who cannot provide it for himself.  Failure to provide medical attention for a dependant person whose physical condition is such as to show that he obviously needs it may amount to neglect... a crucial consideration will be what the dependant person's condition, whether physical or mental, appears to be".

A verdict may influence civil proceedings.  It may satisfy the family or other properly interested persons but it binds no one. 

For further advice on cases involving death whilst under medical care or any questions relating to an inquest, contact our specialist clinical negligence team for confidential advice by calling (0191) 5666500 or by completing our contact form.