We have adopted a specialist team approach to our practices for many years. We feel that this is the way our clients want us to work, and that specialisation leads to the provision of a better service.
We have adopted a specialist team approach to our practices for many years. We feel that this is the way our clients want us to work, and that specialisation leads to the provision of a better service.
Insights
24/04/2025
By Rob Sowersby (Assistant Coroner)
Rob Sowersby is an experienced inquest advocate and sits as an Assistant Coroner in Avon. In this short article, he ventures some tips for those who work in the coroners’ courts.
In January 2025, the current Chief Coroner published new ‘Bench Guidance’ for coroners. The Guidance is clearly organised, wide-ranging, well written and accessible free of charge.
If you are heading towards an inquest and an issue has come up, there’s a good chance there’s something helpful written about it in the Bench Guidance. The Guidance also carries considerable weight, so if you can quote it in support of what you’re asking for, you’ll be on solid ground.
The coroner will hopefully have a decent idea of the evidence they need in order to determine the medical cause of death and answer the four statutory questions: who died, when, where and how?
That said, you may have good ideas yourself about obtaining evidence from additional witnesses, documents from other interested persons (or other organisations), or even independent input from an appropriately qualified expert.
If you want to help shape the inquest, rather than simply participating in it once it’s fully formed, then you need to be involved in that process at the earliest available opportunity. This may involve seeking out disclosure early, reading everything, and thinking from the earliest point you can about what additional evidence is required.
Requests for further evidence can stand or fall on their merits, but they can also fail due to nothing more than bad timing: you can turn up on the first day of an inquest and ask the coroner to obtain additional witness evidence but your chances of success would have been much better if you had asked for the same thing at a pre- inquest review hearing six months earlier. (On that note, if you think a pre-inquest review would be helpful, don’t be afraid to suggest one!)
PIR hearings are an opportunity for you to help the coroner by flagging up the issues in the case and suggesting the evidence that might be required to address them. You can also assist by suggesting a timeline for further evidence in complex cases and giving an indication of which witnesses you think might be required to give evidence in person, and whose evidence can be read instead.
It’s usually helpful to provide clear written submissions ahead of a PIR hearing. This makes it easy for the coroner to see what you want and why. This is also a good time to provide assistance on any tricky areas of law or procedure: if a jury is required because of an obscure point of police law, or if you have a medical case which involves thorny causation issues that the coroner may or may not be familiar with, then your submissions for the PIR hearing are the ideal place to explain your position fully.
You want to be sure that the person in charge of the investigation knows the right questions to ask, as you believe them to be, and the best way to ensure that is to be clear what they are from the outset.
The coroner’s key function is to determine how the person in question died. In most inquests, the word ‘how’ is taken to mean ‘by what means’, so the question for the coroner is normally ‘by what means did X die?’. In itself, this sounds narrow: the answer could be as sad and simple as ‘X jumped from the Clifton Suspension Bridge and died from multiple injuries’.
In such a case though, the coroner would have to consider whether X intended to take their own life: that in turn may involve consideration of X’s mental health history, and of any significant stressors in their life. Where should the lines be drawn though? How far back should the coroner be willing to investigate? How wide should the net be cast? Will the coroner be willing to consider issues such as the impact of X’s benefits being stopped, or, if X was a student, the fact that their tuition had all been given online during a lockdown?
The task of determining which issues will or will not be addressed in the inquest can be a challenging one, but everyone involved in the inquest process will be assisted if the scope of the inquest is set out clearly at an early stage of the investigation.
A well-drafted scope of inquest is a touchstone which is often revisited during the course of an investigation (and even as questions are asked during the course of an inquest itself) and used to assist the coroner in ruling on whether emerging evidence is relevant to, or admissible in, the inquest.
Setting the scope of an inquest is a job for the coroner, but that doesn’t mean that you shouldn’t try to assist in that important process. If you can present the coroner with a sensibly drafted scope of inquest at an early stage in proceedings (and are ready to explain and justify its composition) you will not only assist the coroner, but you’ll put yourself in the best possible position to ensure that the issues you think are important are investigated, or to ensure that extraneous issues are avoided.
If there is one tribunal where advocates would do well to remember the phrase ‘less is more’, it’s in the coroners’ courts. A lot of the most damaging evidence I have seen elicited in inquests has come out by accident as a result of ill-judged or over-enthusiastic questioning by advocates representing interested persons.
The ‘less is more’ maxim is particularly appropriate given that ‘in an inquisitorial jurisdiction there is no requirement for any interested person to traverse via questioning any evidence with which they do not agree’ (see paragraph 26 of the Bench Guidance on ‘Witnesses’). In other words, whether you agree with what the witness just said or not, you aren’t obliged to ask them questions to challenge it.
As a final point, the fact that advocacy in inquests can – and usually should – be very different to advocacy in other courts was formally recognised in 2021 with the joint publication of ‘Competences for lawyers practising in the Coroners’ Courts’, a guidance document endorsed by Cilex, the SRA, and the Bar Standards Board. This short but important document contains, in essence, one page of guidance – we should all be implementing it
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