When is an inquest held after a death?

Section 1 of the Coroners and Justice Act 2009 requires an investigation in three situations: a violent or unnatural death, a death whose cause is unknown, and a death in state custody or detention. The third category is broad — prisons and young offender institutions, immigration removal centres, mental health wards under the Mental Health Act 1983, police custody including transport and arrest, court and military custody, and deprivation of liberty arrangements in care homes and hospitals.

Ordinary and Article 2 inquests

Most inquests answer four narrow questions — who the deceased was, and when, where and how they came by their death — with the "how" typically a single sentence. An Article 2 inquest is different. Where the State may have failed in its duty to protect life, the inquiry expands to "by what means and in what circumstances" the death occurred, opening up the systemic context. It is engaged where the deceased was in state detention or care, or where the State assumed responsibility for their welfare and there is arguable responsibility for an act or omission. In practice virtually every prison suicide, every death in mental health detention and most deaths in police custody fall into this category, and a jury is mandatory for custody deaths where the cause was not natural. Juries can return narrative conclusions identifying specific failures.

What families can do

Bereaved families are Interested Persons under section 47. That gives the right to attend all hearings, be legally represented, question witnesses through a representative, receive disclosure of the investigation materials and expert reports before the hearing, and take part in the pre-inquest reviews that fix the scope of the inquiry — which is where much of the real work happens.

Legal aid comes in two forms: Exceptional Case Funding for representation at the inquest, now non-means-tested for Article 2 deaths in state detention, and means-tested Legal Help for preparation. INQUEST, the Inquest Lawyers Group and the Law Society directory can point you to specialist solicitors.

Where the coroner identifies risks that could cause further deaths, they must issue a Prevention of Future Deaths report, and the recipient must respond within 56 days; both are published. Parallel investigations often run alongside — the Prisons and Probation Ombudsman for deaths in prison and immigration detention, the IOPC for deaths following police contact, and NHS patient safety investigations. Expect 12 to 24 months from death to conclusion. An inquest cannot determine criminal or civil liability, though evidence of possible criminal conduct is referred to the CPS.