Inquests

Coroners hold inquests into the causes and circumstances of death where the death was violent or unnatural or took place in prison or police custody or when the cause of death is still uncertain after a post-mortem.

See also

• Reports to Prevent Future Deaths

Case law

• Inquest cases
• PFD reports

External links

Need to check these:

• Ministry of Justice: Coroners
• HundredFamilies.org: Practical information for families affected by mental health homicides in Britain - website linked to the "Why did you kill my dad?" BBC television documentary
• The Coroners' Society of England and Wales
• Direct.gov.uk: Coroners, post-mortems and inquests
• Ministry of Justice, 'Summary of Reports and Responses under Rule 43 of the Coroners Rules March 2011' (March 2011)
• Guardian: Intervening behind closed doors - 31/3/10 - Mayan Coomeraswamy

INFORMATION

• Representation
  • The role of the mental health lawyer
  • Ethical and other conduct guidance for lawyers
  • Case preparation
• Civil sections and CTOs
  • Section 2: admission for assessment
  • Section 3: admission for treatment
  • Section 4: emergency admission for assessment
  • Section 5: holding powers
  • Section 7: guardianship
  • Community Treatment Order
• Criminal sections
  • Section 37: hospital order
  • Section 37/41: hospital order with restrictions
  • Conditional discharge resources
  • Sections 47, 48 and 49: transferred prisoners
  • Prison sentences
  • Notional s37
  • Section 45A: hospital direction
  • Section 38: interim hospital order
  • Section 135: Warrant to search for and remove patients
  • Section 136: Mentally disordered persons found in public places
  • Section 35: Remand to hospital for report on accused’s mental condition
  • Section 36: Remand of accused person to hospital for treatment
  • Section 37: guardianship order
  • Section 43: committal by magistrates for restriction order
  • Section 44: committal to hospital under s43
  • Section 51(5): hospital order without conviction
  • Detention under insanity legislation
  • Admission order
• Aftercare
  • Patients who are eligible for aftercare
  • The aftercare duty and its duration
  • The definition of aftercare
  • Charging for aftercare services
  • Which authority pays for aftercare
  • Ordinary residence ...
• Mental Health Tribunal
  • Tribunal Rules
  • Preliminary legal points
    • Standard and burden of proof (MHT)
    • Delay (MHT)
    • Re-sectioning after tribunal discharge
  • Tribunal eligibility
    • Eligibility periods
    • Change in status during tribunal proceedings
  • Commentary on some FTT matters
    • Overriding objective (MHT)
    • Applications (MHT)
    • Parties (MHT)
    • Victims (MHT)
    • Representatives (MHT)
    • Notice of proceedings, and listing (MHT)
    • Medical examination (MHT)
    • Remote hearings (MHT)
    • Recording of hearings (MHT)
    • Disposal without hearing (MHT)
    • Hearing in a party’s absence (MHT)
    • Decisions by a single judge (MHT)
    • Reports (MHT)
    • Evidence (MHT)
    • Non-disclosure of documents and information (MHT)
    • Directions (MHT)
    • Adjournment and postponement (MHT)
    • Withdrawal (MHT)
    • Reinstatement (MHT)
    • Decisions (MHT)
    • Public hearing (MHT)
    • Wasted costs (MHT)
    • Appealing against a tribunal decision (MHT)
• Mandatory and discretionary references
• Nearest relative
  • Patients who have a nearest relative
  • Identification of nearest relative
  • Nearest relative powers
    • Nearest relative powers - introduction
    • Nearest relative's right to receive information
    • Right to apply to Tribunal
    • Right to be consulted and to object to s3 admission
    • Right to discharge from guardianship
    • Right to request discharge of s2 or s3 or CTO
    • Dangerousness criterion
  • Changing the nearest relative
    • Delegation by existing nearest relative
    • Displacement (appointment) by county court
  • Nearest relative - miscellaneous
• Legal Aid
  • Contracts
    • Standard Civil Contract 2014
    • Standard Civil Contract 2018
    • Standard Civil Contract 2024
  • Main types of funding
    • Certificated (licenced) work
    • Controlled work
  • Legal Aid eligibility
    • Merits tests
    • Means testing
  • The scheme
    • The mental health fee scheme
    • Hourly rates and fixed fees
    • Escape fee cases
    • Legal Aid for appeals
    • Disbursements, including independent experts
  • Other pages
    • Peer review
    • Transaction criteria
    • Legal Aid in the Court of Protection
    • Legal Aid Agency Liverpool Office
    • Legal Aid forms
    • Legal Aid guidance documents
  • Legal Aid archive
    • Legal Aid information archive
    • Legal Aid News archive
    • Non-means-tested non-tribunal matters
    • Residence test
• International law
  • The ECHR and mental health law
  • The CRPD and mental health law

---

• Changes made by MHA 2007
  • 16- or 17-year-old with capacity cannot be detained on basis of parental consent
  • Abnormally aggressive or seriously irresponsible conduct is only a consideration for learning disability (not personality disorder)
  • Additional safeguards for ECT introduced in new s58A
  • Appropriate treatment test replaces treatability test and applies to all patients under long-term detention
  • Approved Mental Health Professional replaces Approved Social Worker
  • Automatic reference scheme under s68 changed
  • Bournewood gap bridged by Deprivation of Liberty Safeguards inserted into MCA 2005
  • Civil partners are treated as if married when determining nearest relative
  • Conditionally-discharged hospital direction patients can be absolutely discharged by MHRT
  • Domestic Violence Crime and Victims Act 2004 applies to unrestricted criminal patients
  • Fundamental principles set out in Act and included in Code of Practice
  • Higher penalties for offences under Act
  • Hospital direction patients can no longer apply to Tribunal during first six months
  • Hospital directions under s45A apply to any mental disorder
  • Legal status of Code of Practice set out in Act
  • Limitation to the exceptions to the duty to instruct IMCA
  • Mental disorder no longer split into separate classifications
  • Minor drafting error in MCA 2005 corrected
  • New cross-border arrangements for leave and transfer
  • New definition of medical treatment
  • New Independent Mental Health Advocate scheme
  • New procedure for renewal of detention
  • New regulations on conflicts of interest
  • New requirements for age-appropriate accommodation for children
  • NHS Foundation Trusts discharge power problem remedied
  • Organisation of Mental Health Review Tribunal changed
  • Patient can apply to displace nearest relative, who can now be displaced on grounds of unsuitability
  • Patients can be transferred between places of safety under s135 and s136
  • Procedure for making of instruments by Welsh Ministers set out
  • Reference to Local Health Boards inserted into Act
  • Responsible Clinician/Approved Clinician replaces Responsible Medical Officer
  • Restriction orders can no longer be time-limited
  • SOAD certificate becomes invalid when patient loses or gains capacity
  • Some exclusions to definition of mental disorder have been removed
  • Supervised Community Treatment replaces Supervised Discharge
  • Transitional provisions until full implementation of MHA 2007
  • Treatment while under SCT is covered by new Part 4A
• Coronavirus
  • Coronavirus resources
  • Court of Protection and coronavirus
  • Legal Aid and coronavirus
  • Mental capacity and coronavirus
  • Mental Health Tribunal and coronavirus
  • MHRT for Wales and coronavirus
  • MHT for Scotland and coronavirus
  • Remote assessments and coronavirus
• Courts
  • Court of Protection
  • Hospital Managers' Hearing
  • House of Lords
  • Inquests
  • Mental Health Review Tribunal
  • Mental Health Review Tribunal for Wales
  • Mental Health Tribunal
  • Parole Board
  • Upper Tribunal
• Forms
  • Court of Protection forms
  • Judicial review forms
  • Mental Health Act 1983 Statutory Forms
  • Tribunal forms
• General information pages
  • Children and mental health law
  • Civil restraint order
  • Complaints procedure
  • Consultations
  • Electronic signatures
  • Euthanasia and assisted suicide
  • Ian Brady
  • Independent investigations
  • Jury service
  • Leave of absence
  • Mental disorder and driving
  • Ministry of Justice
  • Miscellaneous external links
  • Murder
  • Newsletters
  • Nuisance or disturbance on hospital premises
  • Power to specify hospital units
  • Public tribunal hearings
  • Repatriation
  • Reports to Prevent Future Deaths
  • Smoking
  • Summary of routes to discharge
  • Summary of types of detention
  • Transfer
  • Victims of crime
  • Victims' rights to make representations and receive information
  • Voting rights for detained patients
  • Welfare benefits
• Glossary pages
  • Glossary
  • Key sources of information
  • Other glossary pages
    • Adult Social Care
    • Advance decision
    • Application of MHA 1983 to Armed Forces
    • Barring order
    • Brief glossary
    • British National Formulary
    • Care Programme Approach
    • Compulsory treatment
    • Displacement proceedings
    • Enduring Power of Attorney
    • Extra-statutory recommendations
    • Guardianship
    • High secure hospital
    • Home Office Circulars
    • IPP
    • Judicial review
    • Judicial review pre-action protocol
    • Lasting Power of Attorney
    • Learning disability
    • Mental disorder
    • Part 36
    • Prison law
    • Recall
    • Recommendations
    • Responsible authority
    • Sexual Harm Prevention Order
  • Professionals
    • Appropriate adult
    • Approved Mental Health Professional
    • Approved Social Worker
    • Independent Mental Capacity Advocate service
    • Independent Mental Health Advocate service
    • Responsible Clinician
    • Responsible Medical Officer
    • Second Opinion Appointed Doctor
  • Types of detention
    • All types of detention
    • Summary of the detaining sections
  • Types of discharge
    • Deferred discharge
    • Deferred discharge of unrestricted patient
    • Full discharge of unrestricted patient
    • Summary of types of discharge
    • Supervised discharge
  • Types of patient
    • Restricted patient
    • Technical lifer status
    • Unrestricted patient
• Legislation overviews
  • Mental Capacity Act 2005 Overview
  • Mental Health Act 1983 Overview
  • Mental Health Act 2007 in force dates
  • Mental Health Act 2007 Overview
• Mental capacity law
  • Capacity to consent to sexual relations
  • Court of Protection Practice Directions
  • Deprivation of Liberty Safeguards
  • Interface between MHA and MCA
  • Liberty Protection Safeguards
• Organisations
  • Administrative Justice and Tribunals Council
  • All Party Parliamentary Group on Legal Aid
  • Care and Social Services Inspectorate Wales
  • Care Services Improvement Partnership
  • Civil Contracts Consultative Group
  • Commission for Social Care Inspection
  • Community Care (company)
  • Court of Protection User Group
  • Crown Prosecution Service
  • Department of Health and Social Care
  • Essex Mental Health Independent Inquiry
  • European Union Agency for Fundamental Rights
  • Family Law Week
  • Fixated Threat Assessment Centre
  • General Medical Council
  • Gov.uk website
  • Health Professions Council
  • Healthcare Commission
  • Healthcare Inspectorate Wales
  • House of Lords Select Committee on the Mental Capacity Act 2005
  • HUDOC
  • International Classification of Diseases (ICD)
  • International Journal of Mental Health and Capacity Law
  • Joint Committee on the Draft Mental Health Bill
  • Judiciary
  • Law Commission
  • Legal Ombudsman
  • Legislation.gov.uk
  • MAPPA
  • Mental Health Act Commission
  • Mental Health Lawyers Association
  • National Confidential Inquiry into Suicide and Safety in Mental Health
  • National Mental Health Development Unit
  • National Policing Improvement Agency
  • Office of Fair Trading
  • Office of Public Sector Information
  • Office of the Public Guardian
  • Official Solicitor
  • PPMHG
  • Royal College of Psychiatrists
  • Sentencing Council
  • Solicitors Regulation Authority
  • Statute Law Database
  • Tribunal Procedure Committee
  • Venice Commission
  • Care Quality Commission pages
    • Care Quality Commission
    • CQC - DOLS reports
    • CQC - MHA reports
    • CQC - Other links
    • CQC - State of Care reports
    • CQC - Surveys
  • Charities
    • Bailii
    • Incorporated Council of Law Reporting
    • Inquest (Charity)
    • Mind (Charity)
    • Rethink Mental Illness
    • Social Care Institute for Excellence
• Other jurisdictions
  • Northern Ireland
    • Mental health law in Northern Ireland
    • Review Tribunal (Northern Ireland)
  • Scotland
    • Mental health law in Scotland
    • Mental Health Tribunal for Scotland
    • Mental Welfare Commission for Scotland
  • Southern Ireland
    • Mental health law in Southern Ireland
  • Wales
    • Mental health law in Wales
    • Welsh Assembly emails archive (2010-2012)
• Psychiatry
  • Consent to treatment provisions
  • Covert administration of medication
  • Definition of mental disorder
  • Dual diagnosis
  • Improving Access to Psychological Therapies
  • Insight
  • Psychiatric information
  • Psychiatric medication
  • Psychopathic disorder
  • Treatability test
• Statistics
  • Statistics - Ethnicity
  • Statistics - Ministry of Justice
  • Statistics - Miscellaneous
  • Statistics - NHS Digital - Detention and CTO
  • Statistics - NHS Digital - DOLS
  • Statistics - NHS Digital - Guardianship
  • Statistics - NHS Digital - Other
  • Statistics - Tribunal
  • Statistics - Welsh Assembly Government
• The Law Society
  • Law Society
  • Law Society mental capacity (welfare) accreditation scheme
  • Law Society mental health accreditation scheme
  • Law Society mental health accreditation scheme - CPD requirements
  • Law Society mental health accreditation scheme - guidance documents
• Things to sign up for
  • CPD scheme
  • Email updates
  • Online forum
  • Subscriptions

What links here:

• R (LF) v HM Senior Coroner for Inner South London [2015] EWHC 2990 (Admin)
• R (Speck) v HM Coroner for District of York [2016] EWHC 6 (Admin), [2016] MHLO 1
• R (Ferreira) v HM Senior Coroner for Inner South London [2017] EWCA Civ 31
• R (Silvera) v HM Senior Coroner for Oxfordshire [2017] EWHC 2499 (Admin)
• R (Maughan) v Her Majesty's Senior Coroner for Oxfordshire [2019] EWCA Civ 809
• R (Maguire) v HM's Senior Coroner for Blackpool and Fylde [2019] EWHC 1232 (Admin)
• R (Maguire) v HM Senior Coroner for Blackpool and Fylde [2020] EWCA Civ 738
• Rushbrooke v HM Coroner for West London [2020] EWHC 1612 (Admin)
• R (Lee) v HM Assistant Coroner for Sunderland [2019] EWHC 3227 (Admin)
• Re Lee [2019] MHLO 73 (Coroner)
• Re UR: Derby City Council v NHS Derby and Derbyshire CCG [2021] EWCOP 10
• R (Morahan) v HM Assistant Coroner for West London [2021] EWHC 1603 (Admin)
• R (Boyce) v HM Senior Coroner for Teesside and Hartlepool [2022] EWHC 107 (Admin)
• R (Morahan) v HM Assistant Coroner for West London [2022] EWCA Civ 1410
• R (Patton) v HM Assistant Coroner for Carmarthenshire and Pembrokeshire [2022] EWHC 1377 (Admin)
• R (Maguire) v HM Senior Coroner for Blackpool and Fylde [2023] UKSC 20
• Briley v Leicester Partnership NHS Trust [2023] EWHC 1470 (SCCO)
• Whittle v HM Coroner for North West Wales [2025] EWHC 236 (Admin)