Who Decides How Someone Died? A Court With No Sides

The purpose is to answer four questions about a death, namely who died, and when, where and how they came by their death. It is expressly not to determine guilt or liability, and in several jurisdictions the officer conducting it is forbidden by statute from framing any finding so as to appear to determine criminal liability by a named person or civil liability at all. There is no prosecution and no defence, no charge and nobody in the position of a defendant. The proceeding is inquisitorial, meaning the officer investigates and calls the evidence rather than hearing two sides present competing cases, which is unusual in legal systems otherwise built almost entirely on the adversarial model.

The triggers are defined by statute and are broadly consistent:

• •A death that appears violent or unnatural
• •A death whose cause remains unknown after the usual medical certification
• •A death in custody or otherwise in state detention
• •A death where state involvement or a failure of the state is arguable
• •A death from an industrial disease or an accident at work
• •A death during or shortly after a medical procedure in some circumstances

The hearing produces a conclusion about how the death occurred, drawn either from a defined list including accident, suicide, natural causes, unlawful killing and an open finding where the evidence does not support any of them, or expressed as a narrative setting out the circumstances in a few sentences. Narrative conclusions have become considerably more common because they describe complicated situations that a single word cannot. Where evidence reveals circumstances creating a risk of further deaths, the officer can issue a report requiring the organisation concerned to respond within a set period explaining what it will do, and those reports and responses are published. That power is the mechanism by which individual deaths produce changes in practice, and it is the part of the process with the widest effect.

Most of these hearings are conducted by the officer alone and a minority sit with a jury, and the categories requiring one are revealing about the purpose. A jury is generally required where the death occurred in custody or state detention and the cause was violent or unnatural, where it resulted from an act or omission of a police officer, and where it arose from a notifiable workplace accident. What those share is that the state or a powerful organisation is implicated, so the finding is placed with members of the public rather than with an official. The jury answers the same questions and is bound by the same prohibition on determining liability. Its presence lengthens and complicates the proceeding considerably, which is why the categories are drawn narrowly.

Bereaved families arrive expecting something the process is not designed to deliver, and the mismatch causes real distress. They frequently want a finding that somebody was at fault, which the hearing is prohibited from making. They may face organisations represented by experienced lawyers while having no automatic entitlement to publicly funded representation themselves, which is a long-standing and widely criticised imbalance, particularly where the state is a party to the events. Delays of a year or more are common and difficult to endure. Evidence is given in public and reported. Reform proposals have concentrated on funding for families, on reducing delay and on making the response to reports enforceable rather than merely required, and progress on all three has been slow.

The hearing establishes who died and how, expressly without determining guilt or liability, and it is investigative rather than adversarial. It is required where a death is violent, unexplained, in custody or arguably involves the state. Conclusions are drawn from a defined list or written as a narrative, and reports on risks of future deaths are the mechanism with the widest effect. Families frequently face represented organisations without funded representation themselves.