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A guide to the role of a social worker within an inquest

14 January 2016

Deaths like that of seven year old Blake Fowler, who died in Southampton, or Fiona Pilkington who died in Leicester send shivers down the spines of most social workers. Dismissively, many will think ‘I will never be in that situation’. The reality, sadly, is that you could quite easily find yourself in exactly the same situation, needing to give evidence before a Coroner concerning the death of a child or adult within your caseload which you never saw coming.

Inquests, especially where the death concerns a child, requiring the evidence of social workers are becoming more commonplace. Therefore at some stage during your career as a professional you are likely to find yourself involved in a Coroner’s inquest. Whether that is by way of supporting a family or being called as a witness to give evidence, the process can feel a daunting one.

The purpose of this guide is to explain the Coroner’s investigatory process and to assist you with your preparation for giving evidence as a witness at an inquest, should someone you have had involvement with, in a professional capacity, die unexpectedly.

The purpose of an inquest

The Coroner, who is an independent judicial officer, is required to investigate where:

  • a violent or unnatural death is reasonably suspected,
  • the death is sudden and the cause unknown, or
  • where a death occurs whilst the deceased is retained in custody.

The purpose of the inquest is an inquiry in order to establish material facts. Consequently there are no parties or sides or any pre-formed allegations to answer. The Coroner has to answer the following key questions:

  1. who the deceased was;
  2. when s/he died;
  3. where s/he died;
  4. how s/he died.

In most inquests the main question which needs to be considered is ‘how’ the person died and that can often involve a detailed examination of the circumstances of the death including the health and social care a person received prior to their death.

It is not the role of the Coroner to apportion blame to any individual. Indeed, the Coroner is forbidden from expressing any opinion on civil or criminal liability or naming an individual in their conclusion. However, Coroners can point out shortcomings in the care given and are under a mandatory obligation to consider whether they should issue a ‘Prevention of Future Death Report’ (also referred to as a Regulation 28 Report)) to an agency requesting them to address any such shortcomings (see further below).

When to report a death to a Coroner?

The list below of when to report a death to the Coroner is extensive but not exhaustive. In essence, if the death cannot readily be explained as being due to natural causes it is likely to be reportable to the Coroner.

  • The cause of death is unknown
  • The death is unnatural or suspicious
  • Death is likely due to an accident/self neglect/neglect of others
  • Death occurred in custody or while the deceased was detained under the Mental Health Act (MHA)*
  • Death has been contributed to by the actions of the deceased (including self-harm or suicide)
  • Death is due to an industrial disease or accident
  • The deceased was not seen by the doctor asked to certify death within 14 days of death occurring
  • Death occurred within 24 hours of admission to hospital
  • Death is attributable to medical treatment
  • Death occurred during or shortly after an operation
  • Death is due to murder/manslaughter
  • There are allegations of negligence.

* There is a separate procedure where the deceased is subject to Deprivation of Liberty (DoL).

If you discover a death and are in doubt as to whether a death should be reported to a Coroner, speak to the Coroner’s officer. It is best to be over cautious and report than not to.

Reporting and procedure where DoLS is in place

Many Coroners have issued their own specific guidance on how to deal with a death where a person is subject to DoLS. It is best to contact the Coroner’s officer to discuss the case should you be concerned.

The Chief Coroner also issued the following guidance in December 2014:

  • the Chief Coroner’s present view, subject to a decision of the High Court, is that any person subject to a DoL is ‘in state detention’;
  • when that person dies the death should therefore be reported to the Coroner and the Coroner should commence an investigation;
  • the person is not ‘in state detention’ for these purposes until the DoL is authorised;
  • where the authorisation relates to a care home and the person is removed to a hospital and dies there (or in transit), Coroners should err on the side of caution in deciding that the DoL may extend from the care home to the hospital in cases of medical necessity and therefore an investigation must be commenced;
  • even if the DoL is strictly place-specific, the law of necessity may allow the hospital to ‘detain’ the person, therefore an inquest would be necessary;
  • the investigation cannot be discontinued. There must be an inquest;
  • there is no requirement for a jury where the death was from natural causes;
  • in many cases of this kind which are uncontroversial the inquest may be a ‘paper’ inquest, decided in open court but on the papers without witnesses having to attend;
  • nevertheless, there will always be a public interest in the careful scrutiny of any death in state detention. As in all cases there must be sufficiency of coroner inquiry;
  • Senior Coroners should maintain close liaison with the DoLS lead in their local authority, working together to deal with this extra activity.

The below is not a definitive procedure but is included to provide some indication of how some Coroners are approaching deaths in this area:

How some Coroners are approaching deaths

Coroner’s powers when a death has been reported

The Coroner’s investigation may conclude on the papers alone and without the need for an inquest hearing to take place. Where a death is reported to a Coroner they have the power to:

  • certify that the death is due to natural causes without requiring a post-mortem and discontinue the investigation without holding an inquest hearing
  • certify the death as due to natural causes following receipt of a post-mortem and discontinue the investigation without holding an inquest hearing
  • continue with the investigation and proceed to hold an Inquest even where the post mortem reveals death is due to a natural cause, due to other factors (e.g. neglect)
  • continue with the investigation and proceed to hold an inquest because the post mortem confirms that the cause of death is unnatural.

The procedure

Where a Coroner decided to hold an inquest s/he will ‘open’ the inquest, by publicly sitting in court and recording the personal details of the deceased (‘identification evidence’), the date of death and the brief circumstances understood to surround the death. The Coroner will then adjourn the matter in order to obtain reports/statements (the ‘preparatory’ stage).

Once those reports/statements have been collated the Coroner may hold a ‘pre inquest review’. This is an opportunity for those identified as ‘interested parties’* to attend before the Coroner to set out:

  • the scope of the inquest hearing e.g. the areas which the Coroner needs to consider and hear evidence about to determine how the deceased died;
  • the witnesses required to attend the inquest hearing to give evidence;
  • the witnesses whose statements can be read at the inquest hearing without the need for their attendance;
  • duration and date of the inquest;
  • other evidence required and the timetable for this to be obtained and sent to the Coroner.

*the list of who is deemed to be an interested party is extensive, but is likely to include the family/next of kin/personal representatives of the deceased; the local authority; your employer (where you are not employed by the local authority); you yourself (where circumstances mean that you cannot be represented your employer); the local hospital and/or mental health trust; relevant care home; other relevant agencies.

The ‘preparatory’ stage – witness statements

Very often a number of investigations may occur following a death; the police may be involved; there may be an internal investigation by your employer; a serious case review may have been started and ultimately there will be the Coroner’s investigation. Whilst each of these investigations are separate and are undertaken for the purposes of the investigatory body’s framework (statutory or otherwise), they all help assist the Coroner in determining the question of ‘how’ someone came by their death and s/he is likely to have had disclosure of those investigation reports at the point an inquest is heard.

It is hoped that you will be aware that an inquest is happening before individuals receive a letter from the Coroner requesting a report/statement. However, even though the Coroner is now required to conclude an inquest within six months of a death occurring, very often the circumstances of the death may mean that the other investigations (as mentioned above) and hearings have taken place before the inquest is able to be heard; for example a police investigation and/or criminal trial.

As much support and guidance as possible should be provided to individuals who are asked to provide evidence. A template should be ideally utilised. Given that the statement/report will in due course be disclosed to the family and any other interested parties, it should look professional. More importantly it should be factually correct, contains facts which are within the individuals own knowledge and is accurate. If called to give evidence a witness will be required to affirm or swear on oath/other religious text that the facts of the statement/report prepared are true and accurate to the best of their knowledge.

The ‘hearing stage’

Most inquests are heard by the Coroner sitting alone without a jury, but there are some limited circumstances where a jury (usually consisting of 7 – 11 jurors) will be called, including where:

  • the death occurred in prison or police custody or state detention where the cause of death is unnatural
  • the death resulted from an act/omission of a police officer in the purported execution of their duties
  • the death was caused by an accident, poisoning or disease reportable to a government department
  • the Coroner thinks there is ‘sufficient reason’ to do so.

Unlike any other court hearing before a jury, in an inquest the jurors have a right to ask questions of witnesses. Jurors are elected in the same way as for a criminal court, via the electoral register a random and are discharged if they have any connection with the deceased, witnesses or the interested parties.

The Coroner’s Court is open to the public which means that the press, members of the public, the deceased’s family and other interested parties may be present at the hearing. Sometimes the family and the interested parties will have instructed lawyers for the inquest.

The Coroner ‘chairs’ the inquiry and is in charge of the order in which witnesses give evidence, although this will often be in chronological order according to their involvement with the deceased.

Coroner’s conclusions

Strictly speaking, the Coroner’s conclusion is the full findings of fact regarding the circumstances of the deceased’s death, though usually the term is used to describe the summary.

The Coroner can return either a short form conclusions or a narrative conclusion. A short form conclusion is any of the following:

  • natural causes
  • open
  • accident / misadventure
  • road traffic collision
  • suicide
  • drugs / alcohol related
  • lawful/unlawful killing
  • industrial disease
  • stillbirth.

Remember: the result of an inquest does not ask ‘why’, it seeks only the facts. No conclusion shall be framed in such a way as to appear to determine the question of criminal or civil liability, nor can it name or identify any individual.

Nonetheless, the Coroner (and jury) is encouraged to add an additional statement to the verdict if it is felt the death was aggravated by a lack of care. This is commonly known as ‘neglect’ and is a gross failure to provide basic adequate care and attention which was causative (therefore more than minimally contributed) to the death.

Where the circumstances of how someone came by their death are complicated, Coroner’s use a narrative conclusion. This is factual paragraph setting out how the deceased died. The Coroner may detail the sequence of events leading to death.

Local Safeguarding Boards and Serious Case Reviews


Where a Coroner decides to conduct an investigation into a death or directs that a post-mortem examination should be undertaken and the Coroner believes the deceased was under the age of 18 at the date of death, the Coroner must notify the appropriate Local Safeguarding Children Board (LSCB) within 3 days of making his/her decision.

A Coroner must provide all information that is held by the coroner for the purposes of an investigation and relates to the death of a person who was or may have been under the age of 18 at the time of death to the appropriate LSCB.

Almost in every case concerning the death of child, the LSCB will have started a serious case review. Every agency involved in with the child or family prior to death and during the relevant period will be asked to contribute to this process by providing an agency report.

It is likely that the Coroner will request a copy of the agency report prepared for the purpose of the Serious Case Review, this is a document that the Coroner is entitled to and should be disclosed. If individual statements/interview notes of witnesses are requested there is also an obligation to disclose these. Whilst any statements for the Coroner’s inquest do not need to be identical, the facts contained within them must be consistent.

The Serious Case Review will not be published until the Coroner’s inquest has concluded.


The position regarding adults is not dissimilar to that concerning children. However, because the requirement to carry out a Serious Case Review is not mandatory the Coroners Rules do not oblige the Coroner in the same way as set out above.

Where a vulnerable adult has died following a serious incident and/or abuse or neglect is suspected, the Coroner will be notified at the earliest opportunity and ordinarily this will be co-ordinated by the Adult Social Care Manager. Each area team is likely to have its own protocol; but the deaths arising in the following situation should be reported:

  • deaths where contributory abuse or neglect is suspected particularly domestic violence or services in the statutory, independent or voluntary sector;
  • deaths that occur during a safeguarding adults process;
  • deaths that occur immediately after a Safeguarding Adults Process has been completed within the last 30 days.

Coroners may also be notified when a large scale investigation is started. This will enable the coroner to be aware of providers about which there are significant concerns, they will then know if further enquires are required should a death from that provider come to their attention. They are also informed of services where it is identified there appears to be a high death rate.

The coroner may have specific questions arising from the death of an adult at risk. These are likely to fall within one of the following:

  • where there is an obvious and serious failing by one or more organisations;
  • where there are no obvious failings but the action taken by organisations require further exploration/explanation;
  • where a death has occurred and there are concerns for others in the same household or setting (such as a care home), or
  • when a death occurs outside the requirement to hold an inquest but follow up enquiries/actions are identified by the Coroner or his/her officers.

In the above situations Safeguarding Adults Board will give serious consideration to instigating a serious case review and should a review be undertaken the same process will follow as described above.

Prevention of Future Death Reports (Regulation 28 Report)

Since July 2013, Coroners no longer have a discretion to consider whether to make such a report, but are under a duty to consider whether a report should be made. Broadly speaking reports should be intended to improve public health and safety. The Chief Coroner intends that they should be clear, brief, focused, meaningful and, wherever possible, designed to have practical effect.

A Future Prevention of Death report is directed towards the agency (local authority, health trust, social care provider etc) whom the Coroner believes has the power to make such changes. A report must be made by the Coroner where:

  • something revealed by the investigation (including evidence at the inquest) gives rise to a concern of the Coroner,
  • the Coroner is not restricted to matters revealed in evidence at the inquest,
  • the giving rise to a concern is a relatively low threshold,
  • the concern is that circumstances creating a risk of further deaths will occur, or will continue to exist, in the future if the concern is not addressed,
  • it is concern of a risk to life caused by present or future circumstances,
  • in the Coroner’s opinion, action should be taken to prevent those circumstances happening again or to reduce the risk of death created by them.

Very often, issues identified in any agency Report as part of the Serious Case Review can give rise to Future Prevention of Death Reports if not rectified by the time the inquest is heard.


If you google ‘baby deaths and social workers’ your search will return a number of media headlines, such as:

“vulnerable baby dies after being left in the care of drug addicted mother following multiple failures by social services”

“social workers criticised over death of baby”

It is clear that some deaths are high profile and will attract media attention whether at a local or national level. Inquests are public hearings and thus the press are entitled to attend throughout the inquest hearing. Be aware that they can be there and that the names of witnesses may appear in a news report.


Don’t be fearful of the inquest process (nor any related investigation concerning the death of a child or vulnerable adult). Its purpose and the process is an important one in understanding why someone may have come by their death; ensuring where lessons need to be learned they are learned and to ensure that the bereaved families have answers to questions they have.

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