Laurence Vick
Posted on 20 Aug 2013

Changes to Inquest Rules Promote Transparency

The new Coroners (Inquests) Rules 2013 came into force on 25 July 2013, implementing some of the remaining provisions of the Coroners and Justice Act 2009. The Rules apply to any inquest still on-going as of that date, and completely replace the Coroners Rules 1984.

Coroners' inquests are usually conducted where a death is particularly sudden, violent or unnatural, or where the cause of death is unknown. It is not a criminal trial, even where the eventual determination is 'unlawful killing'; it is the cause of death, rather than who is responsible for it, that is under investigation. Michelmores' clinical negligence team works exclusively with the family of the deceased in inquests, assisting them through what can be a hugely traumatic process. The new rules are seen by practitioners and campaign groups as a welcome step towards streamlining the inquest process, and mitigating its impact on families.


One of the provisions of the new Rules obliges coroners to disclose documents to interested parties as soon as is reasonably practicable, and Michelmores' Alison Starkey believes that this change will help reduce the pressure on bereaved families. Alison, a Legal Executive with extensive experience of working on inquests, is optimistic about the changes. 'Under the previous Rules,' she says, 'coroners' discretion to withhold documents until the commencement of the inquest placed huge stress on families, leaving them unprepared for what could be highly sensitive information aired in public.

'In many cases, we wouldn't see the documents until half an hour before the hearing, and the family would have no time to come to terms with what they contained.' Apart from putting the family's legal team at a significant disadvantage, the emotional consequences of non-disclosure are significant. 'In one inquest I worked on,' Alison says, 'a family were deeply distressed by the contents of the witness statement from the deceased's GP.' The family vehemently objected to the statement, but had no time to formulate a challenge to it. 'Hearing this kind of information in a public setting is clearly not ideal,' Alison says.

Inquests begin soon after the individual's death, and so grief and frustration are still very much a factor. With early disclosure, lawyers can discuss issues with the family to try and minimize their distress, as well as being better able to prepare questions to put to witnesses. According to Alison, 'having more comprehensive disclosure rules also means that there will be less variation between the approaches of different coroners'. This should promote predictability, an essential element in protecting grieving families from greater strain.


Another significant change is Rule 8, which states that 'a coroner must complete an inquest within six months of the date on which the coroner is made aware of the death, or as soon as is reasonably practicable after that date.' Though Alison is uncertain as to how this stipulation will be realised, she does feel that a defined time limit, albeit an optimistic one, will give hope to families involved in inquests. 'Coroners are not well-resourced,' she says, 'and meeting that deadline may prove difficult, particularly in certain regions. But, if it is adhered to, it will represent a good step forward. The family's relief at the conclusion of an inquest is overwhelming, and after that they need some time to decide whether or not to bring an action, such as a negligence claim.'

In contrast to the less positive stories, many coroners are extremely helpful and supportive. Many will hold pre-hearing reviews with the parties and their legal teams, discussing witnesses to be called, the need for experts and documents to be produced, and other relevant issues that are best dealt with at an early stage. There are concerns that the new time limit could in fact cause problems of its own in this regard; a previously obliging coroner, under pressure from the new rules to complete an inquest on time, may eschew pre-inquest cooperation with representatives as a matter of expediency.

However, there are other reasons to be positive. Recent years have seen a widening of the scope of inquests, with the coroner having broader discretion to issue a range of verdicts, and the power to make recommendations. For example, where there have been systemic failures, as seen in hospitals with increasing frequency, an Article 2 or Middleton inquest will be called. This concerns a breach of the state's duty to protect the lives of patients, and is a more wide-ranging inquiry not just into the way the death occurred, but the circumstances surrounding it. The verdicts in this case are far more comprehensive than otherwise. To many families, an early hearing of an inquest comes second in importance to having a full and thorough investigation. In our experience, getting answers to their questions and concerns can bring welcome closure to the family - this is the aspect to keep in focus.

If you would like to discuss an inquest in the context of medical treatment over which you have concerns, please contact our Medical Negligence Team for discreet and impartial advice.