Chief Coroner’s Guidance No.12 The Inquest Checklist
In most cases the inquest can take the following form. The words not in brackets are spoken by the coroner. Coroners may of course use their own words, adapted for the particular case. Bear in mind that the hearing is being recorded and as a record should be complete in itself.
Introduction
1. My name is … I am the senior/area/assistant coroner for the coroner area of ABC.
2. This is the resumed inquest into the death of Michelle XYZ. The inquest was opened on 4 September 2013 when evidence was given of identity. (This is the final hearing.)
3. [Identify persons present including family. Inquire of the family what name they prefer when referring to the deceased.]
4. The purpose of the inquest is
(a) to identify the medical cause of death, and
(b) to answer four questions: who died, when and where did she die, and (perhaps most important of all) how did she come by her death, and
(c) come to a conclusion about her death.
5. This is not a trial. Nobody (no organisation) is on trial. There is no question of attributing blame. That is not the coroner’s role.
6. I shall be calling the following evidence… [summarise in brief].
7. Some of the evidence will be read without the witnesses having to attend. Nobody has required their attendance.
8. You [the family and other interested persons] will have the opportunity to ask questions of the witnesses after I have asked my questions.
9. You can have an audio recording of the inquest later if you wish. So, for the record, today’s date is [date].
Evidence
10. I shall now call the evidence. [Call/read the evidence. Thank the witnesses for coming.]
11. [Make mention of the deceased in life.]
12. The evidence is now concluded.
Retire
13. I shall retire for a short while to consider the evidence and my conclusions.
Findings and conclusions
14. These are my findings and conclusions for the purposes of the inquest.
15. [Summarise the relevant evidence. Explain the medical evidence, and any other expert evidence, in simple language.]
16. [Make findings of fact based upon the evidence.]
17. The four questions – who, when, where and how – can (therefore) be answered as follows …
18. My conclusion as to the death is … [short-form or narrative conclusion, consistent with paragraphs 15-17].
19. The medical cause of death has been established on the evidence as …
20. The details required for the registrar are as follows: [Form 2, paragraphs 1-6].
21. That brings the inquest to an end.
22. [Express condolences to the family.]
23. (I will write a report to … with a view to preventing future deaths.)
HH JUDGE THOMAS TEAGUE QC
CHIEF CORONER
17 December 2013
14 January 2016 revised
7 September 2021 revised