Inquests - Medical Negligence Claims

An inquest is a fact finding Inquiry into the death of an individual(s) which is conducted by a Coroner.  The purpose of an Inquest is to establish the following:

• Who the deceased was;
• When the deceased died;
• Where the deceased died; and
• How the deceased died.

However, not all deaths result in an Inquest.  One must be held if someone dies:

• a violent or unnatural death;
• a sudden death of which the cause is unknown;
• in prison; or
• in such circumstances as to require an inquest under any other act.

An Inquest is a fact finding exercise, its purpose is not to decide who is to blame for the death. 

A post mortem may already have been performed by the hospital pathologist or the Coroner may request a pathologist to perform one.  The purpose of a post mortem is to assist with establishing the cause of death.  Where the coroner requests a post mortem he/she should advise the deceased's next of kin of this intention.  The next of kin has a right to have a pathologist of their choosing attend the post mortem, or to instruct their own independent pathologist to carry out a second post mortem if they are able to pay for it.   

The Inquest Hearing

An inquest hearing is likely to be a public hearing at which the Coroner calls witnesses.  Occasionally, a coroner may also sit with Jury. 

Our role at an Inquest hearing is the take the opportunity to question witnesses who may have important information about the circumstances surrounding the deceased's death. This can be useful when deciding whether or not to pursue a claim for clinical negligence.  Our team of clinical negligence lawyers are experienced at representing families at Inquest and to providing bereaved families with the support they need through the process.  

Inquest Verdicts

There are a variety of different verdicts that a Coroner or jury can make. A Coroner can also make recommendations to the relevant authorities to try and prevent a death from happening again.

Some of the most common verdicts and their meanings are:

Natural Causes

Death by natural causes is death caused by the normal progression of a natural illness which is not contributed to, to any significant degree, by any human intervention.  In the case of a person who has a pre-existing medical condition, the Coroner must consider whether the death was caused by the illness itself or some unnatural intervention which rendered that condition fatal in circumstances where death would not normally be expected (see accidental death/misadventure, below). 

Accidental Death

An accidental death is one where the cause of death was unnatural but not unlawful.  In the context of deaths occurring in the course of medical treatment, a verdict of accidental death would be appropriate where an individual is suffering from a condition that would not in the normal course of events threaten his life and where the treatment itself caused the death. It should be stressed that a verdict of accidental death does not in any way suggest that there was fault on the part of the doctors or health professionals concerned, as it is not the role of the Coroner to comment on the fault of an individual or on issues of civil liability. 

Misadventure

A verdict of misadventure shares many similarities with a verdict of accidental death.  One possible distinction is where a person deliberately undertakes a task which results in death, rather than inadvertent action causing the death.  For practical purposes, however, misadventure and accidental death are considered to be near identical. 

Open Verdict 

An open verdict is an indication that the Coroner or jury have been unable to determine the cause of death on the basis of the evidence they have heard and it indicates that none of the other verdicts have been proved sufficiently.   Where the verdict is being provided by a jury, it is not an indication that the jury have been unable to agree amongst themselves, and for an open verdict to be returned each juror must agree that the evidence was insufficient for any other verdict to be appropriate. 

Suicide

Suicide has been defined as "voluntarily doing an act for the purposes of destroying one's life while one is conscious of what one is doing.  In order to arrive at a verdict of suicide there must be evidence that the deceased intended the consequence of his act." 

In terms of medical negligence, this may arise as an issue where someone under the supervision of mental health professionals commits suicide, but any failures in the care afforded to the deceased may mean that another verdict is more appropriate. 

The consequences of recording a verdict of suicide are significant, and so it must be proved "beyond reasonable doubt" that it was the intent of the deceased to take their own life.  This is in contrast to most of the other verdicts which a Coroner can record which need only be proved by the lesser degree of "balance of probabilities" (i.e. more likely than not). 

Neglect

Neglect requires a gross failure to provide the very basics of life, such as nourishment, liquid, warmth or medicine to someone in a dependent position. There must be a clear connection between the neglect and the cause of death.  Neglect is unlikely to be a verdict in its own right and is likely to be a contributing factor towards another cause of death (for example, "natural causes contributed to by neglect").

Verdicts of neglect are quite rare and, in a medical context, are confined usually to cases where an individual has not been provided with even basic medical attention.  The burden of proof remains 'on the balance of probabilities'.  

Unlawful Killing

A Coroner is not entitled to return a verdict which accuses a named person of any criminal, or indeed civil, liability.  An unlawful killing verdict will apply if the death was caused by murder, manslaughter, infanticide or certain serious driving offences.  In practice, most cases do not come to a full inquest hearing as the inquest is adjourned pending resolution of the criminal proceedings.  It is only resumed if the Coroner considers there is sufficient cause to do so, e.g. that a useful purpose would be served by it. 

It is, however, possible that some cases in the above categories could be put before consideration of the Coroner if, for example, there was insufficient evidence to prosecute any individual or because the "murderer" died during or after the death in question. 

As with a verdict of suicide, the burden of proof on the Coroner or Jury is that the facts must be proven beyond reasonable doubt. 

If you believe you may have a clinical negligence claim, please contact the team by email at clinnegenquiries@kingsleynapley.co.uk or by calling +44 (0)20 7814 1200.