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Jurisdiction note: This guide covers England and Wales. Scotland has a separate system — the Procurator Fiscal investigates deaths and the Sheriff Court holds fatal accident inquiries. Northern Ireland uses coroners under the Coroners Act (NI) 1959. See our inquest reporting guide for wider context.
What is a coroner's inquest?
A coroner investigates deaths that are sudden, unexplained, violent, or occur in custody. Under the Coroners and Justice Act 2009, an inquest must be opened where the coroner has reason to suspect the deceased died a violent or unnatural death, the cause of death is unknown, or the person died in custody or state detention.
The inquest is inquisitorial — the coroner directs proceedings and calls witnesses. There are no parties in the traditional adversarial sense, though interested persons (including families and public bodies) are represented by lawyers and can ask questions. The coroner returns a conclusion, not a verdict.
Hearings are open to the public and press. INQUEST, the charity supporting bereaved families, publishes guidance on inquest procedure at inquest.org.uk.
Types of inquest and conclusions
Standard inquest (no jury)
The coroner sits alone. Establishes the four statutory questions: who, when, where, and how the deceased came by their death. Applies to the majority of inquests.
Article 2 (enhanced) inquest
Where the state may have breached its duty to protect life (deaths in custody, under mental health detention, after alleged NHS failures). The scope is broader and the conclusion addresses whether systemic failures contributed to the death.
Jury inquest
Mandatory in certain cases (death in custody, risk of recurrence, police or military involvement). Also at coroner's discretion. The jury (7-11 members) returns the conclusion. Unlawful killing requires a majority (10-1 minimum).
Short-form conclusion
A single-word or short conclusion: natural causes, accident, misadventure, suicide, unlawful killing, open (where evidence is insufficient to decide). Narrative conclusions are now more common for complex cases.
Prevention of Future Deaths reports (Regulation 28)
A Prevention of Future Deaths report is issued when a coroner believes there is a risk of further deaths unless action is taken. The coroner sends the PFD report to the person or organisation with the power to act — a hospital trust, a government department, a manufacturer, a local authority.
The recipient has 56 days to respond. Both the PFD report and the response are published by the judiciary at judiciary.gov.uk/prevention-of-future-death-reports. The database is searchable by date and subject.
PFD reports are an excellent source of accountability journalism. They identify specific systemic failures, name the organisations responsible for responding, and create a public record of what those organisations did — or failed to do — in response. A series of PFD reports to the same organisation on similar issues is a powerful investigative thread.
Accessing inquest hearings and documents
- Inquests are listed by the local coroner's office — there is no national centralised listing. Contact the relevant coroner's office for upcoming hearings.
- The Chief Coroner's Office publishes guidance and statistics at judiciary.gov.uk/courts-and-tribunals/coroners-courts/.
- Documents disclosed during an inquest are not automatically available to the press — you must apply to the coroner. The family of the deceased often has access to pre-inquest documents; approach them directly.
- The coroner's record (formerly called the inquest file) can be requested via the coroner's office after proceedings are complete. There may be a fee.
- FOI requests to the coroner are generally subject to the Coroners Act exemption under FOIA 2000 s.32, but pre-inquest disclosure requests have had mixed success.
What to focus on when reporting an inquest
- 1The conclusion — including whether it is short-form or narrative, and what the narrative says about how the death occurred.
- 2Any critical comments by the coroner about the actions of public bodies, hospitals, or agencies — these are often the most significant parts of the hearing.
- 3Any PFD report issued — this is the coroner's formal statement of what needs to change.
- 4The response (or failure to respond) of the named organisations to previous PFD reports.
- 5The family's reaction — they are often willing to speak and their perspective gives human context to what might otherwise be dry procedural findings.
- 6Whether this death is part of a pattern — search the PFD database for similar reports before writing.
Common reporting errors to avoid
- Describing the conclusion as a "verdict" — inquests return conclusions, not verdicts.
- Saying the inquest found someone "responsible" for the death — an unlawful killing conclusion does not identify a named individual as criminally responsible.
- Failing to distinguish between the conclusion and the coroner's narrative — a narrative finding may be more critical than the formal short-form conclusion.
- Confusing a PFD report with a finding of fault — a PFD is a preventative measure, not a determination of liability.
- Reporting suicide conclusions in a way that breaches the Samaritans' media guidelines on responsible reporting of suicide.
Pre-publication checklist for inquest reporting
- I have confirmed the stage of proceedings — is the inquest still open, adjourned, or concluded?
- I have distinguished the formal conclusion from any narrative finding — they may be different in emphasis.
- I have checked whether a PFD report has been issued and identified the named recipient(s).
- I have noted any response — or absence of response — from the PFD recipient.
- Where the conclusion is suicide, I have followed the Samaritans' media guidelines on responsible reporting.
- I have not described the conclusion as a "verdict" — the correct term is "conclusion" or "finding".
- Where criminal proceedings arising from the same death are possible or pending, I have applied the strict liability contempt test.
Related guides
Inquest Reporting Guide
Full walkthrough of covering an inquest from listing to conclusion.
Court & Justice Beat
Resources for journalists covering courts as a specialism.
Contempt by Court Type
How contempt rules differ across coroner, criminal, and civil courts.
Attribution in Crime Reporting
Correct language when reporting conclusions and findings.
Frequently asked questions
What is a coroner's inquest and how does it differ from a criminal trial?
An inquest is an inquisitorial (fact-finding) hearing — not an adversarial (contested) trial. The coroner's role is to establish who died, when, where, and how. An inquest cannot make findings of criminal responsibility or civil liability. The conclusion (formerly called a verdict) addresses the factual circumstances of the death. Common conclusions include natural causes, accident, suicide, and unlawful killing. The latter does not name anyone as criminally responsible — that is a matter for the criminal courts.
When is a jury required at an inquest?
A jury is mandatory where the death occurred in custody or in other state detention, in circumstances that may recur (creating a risk to public health or safety), or where the death occurred as a result of an act or omission of a police officer or member of the armed forces in the purported execution of their duty. Where a jury is not mandatory, the coroner has discretion to empanel one. Jury inquests are generally higher-profile and the proceedings take longer.
What is a Prevention of Future Deaths report and how do I find them?
A Prevention of Future Deaths (PFD) report — formally a Regulation 28 report under the Coroners (Inquests) Rules 2013 — is issued by a coroner where the evidence reveals circumstances that, if left unchanged, create a risk of further deaths. The coroner sends the report to any person or organisation with the power to take action. Recipients must respond within 56 days. All PFD reports are published on the judiciary website and can be searched by date, coroner area, and subject. The Chief Coroner also produces annual PFD report summaries.
Can I report anything said at an inquest?
Yes — inquests are generally open to the public and press, and you can report what is said in open proceedings. Absolute privilege in defamation law applies to fair and accurate contemporaneous reports of inquest proceedings, just as it does to criminal court proceedings. There is no automatic contempt risk during an inquest in the way there is once criminal proceedings are active. However, if criminal proceedings are subsequently launched arising from the same death, strict liability contempt then applies.
What is Article 2 and why does it matter for inquest reporting?
Article 2 of the European Convention on Human Rights protects the right to life. Where the state may bear responsibility for a death — in custody, in a psychiatric unit, after a hospital failure — the inquest must be an enhanced (Middleton-style) inquiry that goes beyond establishing the bare facts to examining whether the state's actions or systems contributed to the death. Article 2 inquests produce more detailed findings and the conclusions can refer to neglect or failures by public bodies. They are typically longer and more significant journalistically.
Related guides
Primary sources
- Judiciary — Coroners Courts— judiciary.gov.uk
- Chief Coroner — Annual Reports and Guidance— judiciary.gov.uk
- Prevention of Future Deaths Reports Database— judiciary.gov.uk
- INQUEST — Supporting Bereaved Families— INQUEST
- Coroners and Justice Act 2009— legislation.gov.uk
Not legal advice. This guide is for educational purposes. Consult a qualified media lawyer before making publication decisions in legally sensitive situations.