Inquests and Investigations

In England and Wales, all unexpected deaths (such as possible suicides, accidents or homicides) must be investigated. The death will be reported to the local coroner, who will usually hold an inquest. 

After someone dies, their body is taken to a mortuary. Someone (usually the next of kin) will be asked by the police or the coroner’s officer to identify the person and sign a statement to confirm their identity. This can be a difficult thing to do, so consider asking a friend or relative to go with you. 

Although this may not happen immediately, the police or the coroner’s officer will take statements from people who can help with the investigation, such as family, friends, the person or people who found the body and any witnesses to the death. You can ask for a copy of the statements you make, in case you want to refer to them at the time of the inquest, although because they are legal documents this is not always possible. 

It might be necessary to take photographs of the location where the body was found. If a message such as a note or phone recording was left, the police will need to take it as evidence. Some coroners will let you have a copy, although you have no legal right to keep the note. You can ask for the original to be returned after the inquest if it was addressed to you. It might be useful to make a note of the names of the police officers or coroner’s officers you come into contact with and to ask for receipts for anything they take away. 

What does the coroner do?

The coroner is an independent, judicial officer appointed by the local authority to investigate sudden, unnatural and violent deaths. Most coroners are lawyers, though some are doctors; very occasionally they are both legally and medically qualified. 

The coroner’s job is to find out who has died and how, when and where they died. The coroner does this by holding an inquest and reaching a conclusion on the cause of death. Coroners are helped by coroner’s officers (who are sometimes former police officers), and in some parts of the country, the coroner is assisted by the police and clerical staff. 

The post-mortem

The coroner will usually arrange for an examination of the body by a pathologist, to try to find out the exact cause of death. You can ask to have a copy of the post-mortem report; however, these are usually written in a very factual, impersonal way and may include details that you will find upsetting. 

What does the coroner’s office do?

The coroner’s officer will be the person with whom you have most contact. They should explain what will happen at the inquest and try to answer any questions you may have. They make sure that all the evidence is available for the coroner before the inquest takes place. They may also take statements and obtain reports for the coroner. 

What is an inquest?

An inquest is a public, legal inquiry to find out the facts about the death and deliver a conclusion on the cause of death. It is not a trial and is not intended to blame anyone. It is usually held in a courtroom, which some people find intimidating. You could ask the coroner’s officer to arrange for you to visit the courtroom beforehand and explain what to expect. 

The coroner normally opens the inquest within a few days of the death but where there is uncertainty as to the cause of death may open an investigation in the first instance. The opening of an inquest usually involves a short hearing and formal identification of the person. The coroner will then release the body for burial or cremation and issue an interim death certificate. The inquest is then adjourned until all the necessary information is gathered. This may take some months or, very occasionally, more than a year. If the death took place in custody or while the person was in hospital or in psychiatric care, the inquest might be delayed while special reports are prepared or a separate investigation is held. 

At the full inquest, the coroner will call witnesses such as police, other relevant people (for example, the pathologist who carried out the post-mortem), doctors, family members and other witnesses, to give evidence. Statements given to the police, including what relatives have told them, may be read out. If you do not have a copy of your own statement, you can ask the coroner’s officer to provide one, although not all will agree to this. The coroner may ask questions of the witnesses. It is unusual for the full content of any messages left by the dead person to be made public. 

Who can attend the inquest?

Any member of the public can attend an inquest. Close relatives must be given details of the time and place of the inquest in advance. You do not have to go to the inquest unless you receive a notice from the coroner requiring you to give evidence. Members of the press are likely to be in court. 

Can I leave the court if I want to during the inquest?

You can leave the court at any time (except when you are giving evidence) and come back when you want. Some coroners will tell you when the post-mortem or other evidence that might be distressing is coming up, so that you can leave if you want to. 

Will there be a jury?

Most inquests are held without a jury, but sometimes, for example when the death took place in prison or in police custody, a jury will be called and will decide the conclusion. 

Who can ask a witness questions?

Anyone who has a ‘proper interest’ – such as a parent, spouse, partner or child of the dead person – may question a witness. You can get a lawyer to ask questions for you, or ask them yourself. Talk to the coroner’s officer in advance if you plan to do this. 

The conclusion

The coroner will only give a conclusion of suicide if an act was self-inflicted and if (in their opinion) it was intended to cause death. If this is not proved, the coroner will usually give an open conclusion, although sometimes another conclusion such as ‘accidental death’ or ‘misadventure’ may also be given. While some people can accept this, for others the lack of a definite suicide conclusion and the feeling that the inquest does not answer all their questions about why the person died make it more difficult for them to come to terms with the death. 

Can I get a report of the inquest?

The coroner will make a recording of the proceedings. You can apply to the coroner for a copy of the recording of the inquest. Coroners must keep their records for 15 years (some keep them longer). 

What happens after the inquest?

The coroner will tell the Registrar of Births, Marriages and Deaths of the conclusion, so that a final death certificate can be issued. The coroner’s officer will tell you how to get final death certificates. 

You will need more than one copy to send to banks, building societies, insurance companies and other organisations. 

Will there be a report in the newspapers?

When someone has died by suicide or in another traumatic way, it may attract public interest for reasons which may not always be easy to understand. The inquest also draws attention to the person who has died and the circumstances may be reported by the media. This can be very stressful, particularly when a report is insensitive or inaccurate, for example where it focuses only on the problems the person may have had without mentioning the good things about them. 

You may find yourself approached by journalists and photographers for details of your loved one. This can be particularly true when the death has occurred in a public place, or if a young person has died. 

Remember that you do not have to co-operate and you do not have to say anything about the person who died. Equally you can ask the media not to report the person’s death – this can sometimes work. 

Some bereaved people have found the local media tactful and supportive and have even had the opportunity to approve the newspaper report before it was published. 

If media interest is expected, then some families prepare a written statement about the person who has died which includes a description of them (name, age, what they were like and enjoyed, how they will be remembered etc.). In this way you may have a little more control about what is said or written. 

This statement could also say whether you are prepared to comment or be interviewed now or later. Before agreeing to speak to a journalist, it is always wise to consider the possible implications of making information public. There is no guarantee the media will use what you provide. They may choose to do their own research using publicly available information. This could include using photographs from social media accounts. 

You may want to provide a photograph yourself. However it’s worth noting that once the media have a photograph, it can be used at any time – for example when a similar event happens. There may be no preparation for suddenly seeing a photograph of someone you know reappear months later in connection with a different event. 

Sometimes, appropriate media coverage can feel like a way of sharing the life of a person with a wider audience. Some people choose to talk publicly as a way of remembering the person or to raise awareness of the issue of suicide to help prevent further deaths. You should do whatever you feel comfortable with. 

There are clear media guidelines issued by the Samaritans about how to report appropriately on a suicide death and you should complain if you feel these have been broken. The Samaritans Cymru communications team can support you in this and the Chair of the National Advisory Group can also write to editors about this issue. You can also complain to the Independent Press Standards Organisation if you have been subject to intrusive enquiries or if you are concerned that coverage may affect other people’s safety. The police press officer or police family liaison officer are also people you could ask for advice about dealing with the media. 

Social Media

An increasingly common aspect of bereavement is social media. You may want to keep what has happened private, yet versions and comments may already be circulating on the internet. This is one reason why, although it is painful and hard, it may be worth considering being honest about how the person died.

You may want to post a message about the death on the social media pages of the person who has died or on your own pages. Before you do, think about if there might be a more gentle way of letting people know. Consider also who will read it, now and in the future, and that they may not react with kindness which can be very distressing.

After a death, social media pages can also be used as a place for people’s memories and photographs of the person who has died. Many people talk about the comfort that sharing these memories can bring. It can be a helpful way to continue to mark birthdays and other important anniversaries.

You can request for social media pages to be deleted on the persons death. This is not always possible and sometimes you will be requested to produce the death certificate.

Deaths of people in contact with mental health services

People with mental ill-health have a higher risk of taking their own lives than others. If someone who is in touch with mental health services takes their own life then it is usual for the health board that was providing their care to conduct an audit of the case. This means that they will look at the circumstances of the suicide to see if there are any lessons to be learnt. The health board may contact members of the person’s family as part of this process.

Deaths in custody

Every death in prison in England and Wales is subject to a police investigation, an independent investigation by the Prisons and Probation Ombudsman and a coroner’s inquest held before a jury. The prison family liaison officer usually informs the family about the death, offers support and gives practical help and advice. They are the single point of contact with the prison and liaise with other agencies, particularly the coroner’s office. They will arrange a visit to the prison to meet staff and prisoners who knew the person who died. They also liaise with the Chaplain about a memorial service, organise payment of reasonable funeral expenses, help with arrangements for and attend the funeral, and manage the handover of property.

Deaths in the care or custody of the police

Where there is a death in police custody or a death that is closely linked to contact with the police, it has to be referred to the Independent Police Complaints Commission (IPCC). The IPCC may independently investigate the death, or manage or supervise a police investigation into the death.

The IPCC provides a dedicated family liaison manager, in the majority of independent investigations, to keep the family informed and explain any aspects of the process; in managed and supervised cases, the IPCC is likely to work closely with a police family liaison officer to provide this single point of contact, to minimise bureaucracy.

There will also be a commissioner in charge of the case who is completely independent from the police. They will make decisions such as whether the case should be passed to the Crown Prosecution Service to consider criminal charges, or whether any member of the police service should be disciplined.