Practising in the Coroner's Court

We have developed these resources, which include a set of competences, to help you better understand the standards that we expect of solicitors who practise in inquests. You can use these resources to help you identify and address any learning and development needs in this area.

We developed these resources in partnership with The Bar Standards Board and CILEx Regulation, with support from:

• The Chief Coroner and their office
• The Deputy Chief Coroner and Senior Coroner for Sunderland
• Solicitors and barristers who practise in inquests
• Members of the public who have been involved in inquests
• The Ministry of Justice
• The charity INQUEST
• The Coroners' Court Support Service

Below are outlined the competences we expect from solicitors who practise in inquests in the Coroners’ Courts. They reflect the main challenges of practising in inquests, and contextualise some of the requirements of our wider Competence Statement.

Read the competences for practising in inquests in full.

The competences should be used to help you identify if you are meeting the standards we expect and, if not, where you should focus your learning and development.

To help meet the competences, you should make sure you:

• have good knowledge of case law, legislation and relevant guidance on inquests
• understand how to communicate and engage effectively with vulnerable people before, during and after an inquest
• understand how to adapt the style of your advocacy and questioning to inquests and to vulnerable people
• are aware of the organisations and forms of support which exist to help people taking part in inquests

As inquisitorial proceedings, inquests are limited fact-finding inquiries. Unlike most other court proceedings, they do not seek to determine criminal or civil liability. Reflecting this difference, your role as an advocate in inquests is to help the coroner (and occasionally a jury) find facts as to the identity of the deceased and when, where and how their death occurred, without trying to determine liability. 

This important difference means that, when you take part in inquests, you need to:

• adapt your style of communication and engagement to the purpose of inquests
• make sure that people understand the purpose of the inquest and their role within it
• make sure the style of advocacy and questioning you use is suited to inquisitorial proceedings and the sensitivity of inquests.

You also need to think carefully about how you communicate and engage with people who are vulnerable. Vulnerability comes in many forms. Bereaved families, who play a central role in inquests, are often vulnerable because they are grieving the loss of a relative. They can also be vulnerable because they:

• are unfamiliar with the inquest process
• do not have a lawyer to represent them, even if other parties are represented
• do not understand how the inquest process differs from other proceedings they have already been involved in or expect to take place, such as ombudsman investigations or criminal proceedings into the death of their relative.

It is important to remember that other interested persons or witnesses may also be vulnerable. For example, emergency service staff and prison staff can experience trauma as a result of witnessing or being involved in a person’s death.

Thinking carefully about how you communicate and engage with vulnerable people in an inquest can help you to:

• make sure they understand the purpose of the inquest and their role within it
• assist the coroner in making sure that the inquest runs smoothly
• identify any adaptations that need to be considered by you or the court

You should also think about your behaviour outside court, as it may have an impact on the people who take part in an inquest. For example, members of a bereaved family could be upset if they overheard informal or inappropriate conversations between lawyers.

How you can communicate and engage effectively in inquests

You can use the information below to help communicate and engage effectively during an inquest.

Preparing

Make sure you:

• have a good understanding of the jurisdiction and purpose of the inquest, the circumstances of the death in question and the possible vulnerability of the people who are involved
• manage your client’s expectations by making sure they understand the purpose of the inquest, their role within it and what they can expect from you
• make sure your client understands what to expect from you, and consider whether it would be helpful to signpost them to these resources or any wider sources of information or support.
• engage with other parties to the inquest in advance if it could help the inquest to run smoothly
• are aware of any issues that should be raised or agreed in advance of the inquest, for example, your client’s vulnerability, condition or impairment which requires adjustments or adaptations.

Delivery

Your communication and engagement needs to reflect the sensitive nature of the inquest and that your role is to assist the coroner in finding facts as to the identity of the deceased and when, where and how their death occurred, without trying to determine liability. To help do this, make sure you…

• use plain language to make points and ask questions in a clear and simple way, so that the people involved in the inquest can understand them
• avoid the use of idioms and unnecessary legal jargon, terminology or acronyms
• repeat, explain or rephrase your questions or points if they are not understood by the people taking part in the inquest
• refrain from using inappropriate emotional language
• Make sure your questions and submissions are relevant to the purpose of the inquest and appropriate. In particular, recognise that whilst firm and robust questioning may sometimes be necessary, an aggressive and hostile style of questioning is not appropriate.
• Adapt your questions and submissions to the circumstances and possible vulnerability of the people involved in the inquest. For example, challenges to evidence and the appropriateness of conduct may be required, but this should be proportionate to the nature of the issues in the inquest and take account of both family and witness vulnerabilities. Questions to vulnerable witnesses, children and the bereaved are likely to be different to questions to experts, such as pathologists, and professional witnesses, such as medical staff
• Avoid duplication of areas covered by the coroner by making sure that your questioning explores areas not raised by them or in a way that goes further than the issues covered by their questioning.

A number of organisations provide advice and support to people who take part in inquests. You should signpost or make a referral to them if it would benefit your client and help the inquest run smoothly.

The following organisations were involved in the development of these resources:

• The Coroner's Court Support Service is an independent charity and voluntary organisation, which provides practical and emotional support to bereaved families, other interested parties and witnesses who take part in inquests. Its trained volunteers run a confidential telephone support service and provide in person support in the Coroners' Courts.
• Inquest is a charity which gives expert support on state related deaths to a range of people including bereaved people and lawyers. It provides useful resources and free, independent advice on the inquest process for state related deaths.

Here are some other organisations which provide support to bereaved people.

• Action against Medical Accidents provides support to people who are involved in an inquest into a death following medical treatment, including an information leaflet.
• CRUSE Bereavement Care provides support to bereaved people, including a helpline and a number of local branches.
• The Good Grief Trust aims to help bereaved people by bringing together all of the bereavement support services that exist in the country in one place.
• The Hub of Hope is a mental health support database run by Chasing the Stigma, a mental health charity. People experiencing mental or emotional distress can enter their postcode to find out about local, national, peer, community, charity, private and NHS mental health support and services.
• Survivors of Bereavement by Suicide (SOBS) provides a range of services for people who are bereaved as a result of suicide including support groups, a helpline and email support.
• The Compassionate Friends offers support services, including a helpline, to people who are grieving the loss of a child.
• Winston's Wish provides information and support services to grieving children.
• Samaritans can help anyone who is experiencing a difficult time and in need of support, including bereaved people.
• The Bereavement Advice Service is run by Co-Op Legal Services. It offers practical advice and information on the issues and procedures after a death, via a free helpline and online resources.

It is important that you keep the knowledge and skills that you need to practise effectively in inquests up to date. The key things to remember are:

• regularly reflect on your knowledge and skills to identify any learning and development needs
• address your learning and development needs to make sure that you are competent to practise.

You can use the following resources to help reflect on your competence to practise effectively in inquests. They should be used alongside our competences and resources for solicitors who practise in inquests, as well as our Statement of Competence and our continuing competence resources.

• The Office of the Chief Coroner maintains a range of resources including guidance and general advice from the Chief Coroner, a summary of key cases, annual reports and FAQs.
• The Ministry of Justice Guide to Coroner Services for Bereaved People gives a detailed overview of the purpose of inquests and the different stages of the inquest process. It is useful for anyone involved in inquests, including lawyers.
• The Coroners’ Society of England and Wales regularly updates the announcements section of its website and has a section of links to important external organisations and resources.
• The Advocates’ Gateway has a wide range of free toolkits to help lawyers to communicate and engage effectively with vulnerable people during court proceedings.
• Advocacy and the Vulnerable is a national training programme for lawyers who engage with vulnerable people during court proceedings. The training is endorsed by The Law Society and can be booked through its website. The training includes an online course, virtual classroom-based training and a reflection element.
• Chapter 2 of the Equal Treatment Bench Book includes useful and practical information about how lawyers should adapt their style of advocacy and questioning when dealing with people who are vulnerable.

The following questions can help you identify any gaps in your knowledge about practising in inquests in the Coroners’ Courts. You should address any gaps by undertaking learning and development.

• Do you have good knowledge of case law, legislation and relevant guidance on inquests?
• Do you understand how to communicate and engage effectively with vulnerable people before, during and after an inquest?
• Do you understand how to adapt the style of your advocacy and questioning to inquests?
• Do you understand how to adapt the style of your advocacy and questioning to vulnerable people?
• Are you aware of the organisations and forms of support which exist to help people taking part in inquests?

If you think that another solicitor has not met our standards, then please refer to the Reporting an individual or firm section of our website or call our contact centre.

If your concern arises during an inquest, it may be appropriate for you to raise it directly with the coroner in charge. Coroners are aware of the standards that solicitors should provide during inquests and may be able to resolve issues quickly.