The Coroner: role, inquiry, inquests
2.8.11 The purpose of an inquest is often misunderstood, not least because as a court there is a commonly held assumption, and an expectation, that it is concerned with establishing liability - that a person, persons or organisation will be held responsible for committing an act or for failing to act, thus contributing to a death.
2.8.12 This is not the case. While civil and criminal courts are adversarial, establishing liability on the evidence presented by opposing parties, the inquest has a 'very limited objective': to establish who the deceased was; 'how', 'when' and 'where' the deceased 'came by his [sic] death'; and the 'particulars' required for registration of the death. Most deaths are registered without an inquest.
2.8.13 Where there is concern as to the cause of death, however, the coroner is obliged to hold an inquest. In cases of deaths in controversial circumstances, including serious accidents where negligence is alleged, the coroner will open an inquest and immediately adjourn proceedings to allow for criminal investigations to progress and the question of criminal prosecution to be considered.
2.8.14 Coroners are independent of government and are medically or legally qualified. The primary objectives of the inquest, usually explained by the coroner at its opening, are to confirm the identity of the deceased, establish when and where they died and explore how they died.
2.8.15 In establishing the medical cause of death, particularly in high-profile cases, coroners work closely with pathologists. Although ascertaining 'who', 'when' and 'where' might be contested, these elements of a case are usually straightforward. They establish a person's identity, the approximate time of death and the place where death occurred.
2.8.16 Exploration of 'how' death happened, however, requires detailed investigation of the circumstances. Deaths in controversial circumstances often involve significant differences in witnesses' evidence and in professional opinion including contrasting interpretations of 'fact' by pathologists or other 'expert' witnesses.
2.8.17 In contentious cases when insufficient evidence has been gathered to support a criminal prosecution against those whose action or inaction might have contributed to a death, the full weight and expectation of responsibility fall inappropriately on the inquest.
2.8.18 Supported by coroner's officers, often local police officers on secondment, the coroner conducts and directs the preliminary investigation, gathers evidence, and determines the extent to which, if at all, families or other interested parties may have any access to such evidence. The bereaved have little or no access to legal aid and the costs of legal representation, particularly in complex cases, are considerable and prohibitive.
2.8.19 From his/her investigation the coroner decides the witnesses to be called to give evidence at the inquest, taking into account any representations from families or other 'interested parties', none of whom has any right to call witnesses themselves. Witnesses are examined first by the coroner followed by examination by interested parties.
2.8.20 The coroner organises the sequence in which evidence is presented and examined, the scope of questioning by 'interested parties' and the conduct of the inquest. Inquests usually rely on oral evidence, often supported by written statements.
2.8.21 When inquiring into the cause of death 'in circumstances where the continuance or possible recurrence of which is prejudicial to the health and safety of the public or any section of the public', the coroner is obliged to summon a jury. Juries are selected usually from the local population in the jurisdiction where death occurred and they comprise of seven to eleven jurors.
2.8.22 The jury hears the evidence presented at the inquest and its examination by 'interested parties'. Only the coroner can address the jury, summarising the evidence and providing legal direction. The coroner puts to the jury the verdicts, from a prescribed list, he or she considers consistent with the evidence, directing towards the verdict closest to his or her interpretation. After deliberation the jury returns the verdict with the possibility of adding a narrative commentary. Narratives, however, were not permitted in 1990.
 Griffiths, J R v Hammersmith Coroner, ex parte Peach in Ward, T 'Coroners' Inquests 2: The Inquest' Legal Action Bulletin February 1984, p16.
 Rule 3b of the 1984 Coroners' Rules in Kavanagh, G. Coroners' Rules and Statutes London: Sweet and Maxwell 1985 p52. Since the introduction in 2000 of the Human Rights Act 1998, whereas 'how' is to be understood as 'by what means', in the usual case, it is to be understood as "by what means and in what circumstances' in cases where ECHR Art 2 requirements have to be met by the inquest.
 Coroners Act 1988, Section 8(3)(d).