The conduct of inquests (2016/01)
This Practice Note applies to the conduct of all inquests in the Coroner’s Court. References to ‘the Act’ are to the Coroners Act 2006. The Practice Note is to be read in conjunction with the Act. In the case of any inconsistency, the Act is to prevail.
2. Commencement of this practice note
This Practice Note will apply from 22 July 2016 to all inquests relating to deaths reported on or after 22 July 2016.
The Practice Note covers the following matters:
- Identification of issues
- Identification of interested parties
- Notification to immediate family and other interested parties
- Rights of immediate family and other interested parties
- Documents and information
- Pre-inquest conference
- Inquest bundle
- Expert evidence
- Evidence at the inquest
- Submissions after conclusion of the evidence
- Notice of adverse comment
This Practice Note is intended to improve the quality, consistency and timeliness of inquests.
5. Conduct of inquests
Identification of the issues
 At the time of the decision to hold an inquest the coroner will identify the issues which are to be addressed.
 The coroner will identify the issues based on the information available to the coroner at that time. The coroner may modify or supplement the issues as further information is received.
 Where the coroner has identified the possibility that a recommendation may be made under section 57(3) of the Act, this is to be listed as one of the issues to be addressed at the inquest.
 The coroner will give the immediate family of the deceased1 and any other interested parties the opportunity to comment on whether the issues have been properly identified. The coroner will then consider whether to modify or supplement the issues based on any comments from these people.
Identification of interested parties
 Where an inquest is to be held, the coroner will identify all interested parties:2
- a person who is recognised under section 22 as a representative of the immediate family of the person who is, or is suspected to be, dead; and
- a member of the immediate family of the person who is, or is suspected to be, dead who has asked to be notified of matters, and has given the responsible coroner contact details for that purpose, because the member considers that the member’s interests are not represented by a representative recognised under section 22; and
- a person whose conduct is, in the view of the responsible coroner, likely to be called into question during the course of any inquiry in relation to the death or suspected death; and
- any other person or organisation that the responsible coroner considers has an interest in the death or suspected death (apart from any interest in common with the public).
Notification to immediate family and other interested parties
 The immediate family of the deceased and other interested parties are to be notified of:
- the issues which the coroner has identified and which are to be addressed at the inquest; and
- any amendment to the issues which the coroner makes as a result of receiving further information or after considering comments from the immediate family or other interested parties about the proposed issues; and
- the documents which the coroner holds which are relevant to the issues to be addressed at the inquest; and
- the time, date and place of the pre-inquest conference; and
- the time, date and place of the inquest.3 Such notice is to be given no less than 10 working days before the date fixed for the inquest.
 The immediate family of the deceased and other interested parties are to be notified of these matters in the manner specified in sections 22 and 23 of the Act.
Rights of immediate family and other interested parties
 The immediate family of the deceased and other interested parties have the following rights in relation to an inquest:
- to be notified of the matters set out in paragraph ; and
- to comment on whether the issues which are to be considered at the inquest have been properly identified by the coroner or whether they should be modified or supplemented; and
- to attend the pre-inquest conference, either personally or by counsel; and
- to be provided with a copy of documents which the coroner holds which are relevant to the issues to be addressed at the inquest; and
- to invite the coroner to consider receiving evidence in addition to that which the coroner has obtained in the course of the inquiry; and
- to make, and to oppose, applications to the coroner in relation to any matter relevant to the inquiry, including any application for in-court media coverage; and
- to appear at the inquest, either personally or by counsel; and
- to cross-examine any person who gives evidence at the inquest, subject to the notice requirements in s77; and
- to make submissions to the coroner in relation to the issues.
Documents and information
 The coroner will provide copies of documents received in the course of the inquiry which are relevant to the issues to be addressed at the inquest to the immediate family and other interested parties upon request.
 Where the coroner receives any information which the coroner intends to take into account in determining the issues, this information will be provided to the immediate family of the deceased and other interested parties and they will be given an opportunity to comment on it. If the information is to be included in the bundle (see paragraph ) it need not be provided separately.
 Where the immediate family or another interested party wishes to make an application to the coroner, they should notify the coroner of the type of application they wish to make. The coroner will then make directions to address the application.
 The hearing of the application may be recorded or transcribed as directed by the coroner.
 Where an inquest is to be held, the coroner will fix a date for a pre-inquest conference. More than one pre-inquest conference may be required.
 A pre-inquest conference may take place by teleconference or in Court.
 The following matters will be addressed at a pre-inquest conference:
- whether any person considers that the issues identified by the coroner should be altered or supplemented; and
- whether any pre-inquest applications are to be made and if so, a timetable for resolution of these; and
- the date, time estimate and place for the inquest. The place of the inquest is to be determined under section 81(3) of the Act; and
- the witnesses whose evidence will be considered by the coroner and:
- whether the evidence can be received in written form with no requirement for the witness to attend the inquest; and
- whether the witness is required to attend and be cross-examined at the inquest and, if so, whether the evidence-in-chief of that witness may be read from a statement or should be given viva voce; and
- where the immediate family or another interested party wishes to cross-examine a witness:
- the areas of evidence which they wish to explore; and
- whether they intend to call into question any action or inaction of the witness; and
- the order of witnesses and likely time required for the evidence of each witness; and
- whether any witnesses should be excluded from the Court while other witnesses are giving evidence; and
- whether expert witnesses should confer in the manner set out in the Code of Conduct for Expert Witnesses and whether their evidence should be given at the same time; and
- the documents which are to be considered by the coroner at the inquest; and
- the preparation of an inquest bundle; and
- whether any orders are required in relation to the attendance of the media.
 A pre-inquest conference may be recorded or transcribed as directed by the coroner.
 Following a pre-inquest conference, the coroner will issue a Minute summarising the outcomes of the conference and setting out the directions which have been made.
 The coroner will decide how the inquest bundle is to be prepared. However in general the bundles must be paginated and include an index unless the coroner directs otherwise.
 The coroner will provide a copy of the inquest bundle to the immediate family and interested parties where requested to do so. It may be provided in electronic form unless the recipient is unwilling to receive it in this way.
 However, where the coroner has already provided a copy of documents under clause  the coroner is under no obligation to provide the same documents twice. In this case the coroner may provide only the index to the inquest bundle to that party.
 The immediate family of the deceased or any other interested party may invite the coroner to receive evidence from an expert witness in relation to any of the issues.
 A coroner may receive expert evidence from an expert during the inquiry.
 Evidence from any expert must comply with the requirements of the Code of Conduct for Expert Witnesses in Schedule 4 of the High Court Rules.
Evidence at the inquest
 Where a witness is not required for cross-examination at an inquest, a coroner may admit the evidence of that witness if the evidence has been put into writing, read over by or to the witness and signed by the witness4.
 Where a witness is required for cross-examination, the evidence in chief of that witness may be given by tendering a previously prepared written statement and confirming it on oath or affirmation, subject to section 90 of the Act.
 A coroner may exclude a witness from the Court until he or she gives evidence.5 However, a coroner will not exclude an expert witness from the Court while another expert witness is giving evidence unless either expert is also giving disputed factual evidence in relation to an issue which is being considered at the inquest.
 The coroner will consider:
- requiring expert witnesses to confer before the inquest; and
- hearing the evidence of two or more expert witnesses whose evidence relates to the same issue at the same time. In this case the expert witnesses will all be sworn in at the same time and will give their evidence and answer questions in a manner directed by the coroner.6
Submissions after conclusion of the evidence
 After conclusion of the evidence the coroner may give the immediate family of the deceased and other interested parties an opportunity to make submissions about the issues. The coroner may receive these submissions orally and/or in writing.
 Any in-Court media coverage applications are to be dealt with in the manner set out in the current edition of the Media Guide for Reporting in the Courts and Tribunals.
 Where the coroner receives a media coverage application, the coroner will provide a copy to the immediate family of the deceased and other interested parties and give them an opportunity to be heard in relation to the application.
Notice of adverse comment
 Where a coroner indicates an intention to make an adverse comment under section 58 of the Act, the coroner may send only those sections of the draft findings to the recipients which are necessary to give that person a reasonable opportunity to be heard in relation to the proposed comment.
 Where the coroner intends to make a recommendation or comment, the coroner will send a draft of the recommendation or comment to:
- any expert from whom the coroner has received evidence under s76, and
- any other expert the coroner considers has an interest in the inquiry, and
- any persons or organisations to whom the recommendation or comment is directed.
 The coroner will give those persons or organisations 20 working days to comment on the proposed recommendation or comment. The coroner will consider any response received in the timeframe provided before making the recommendation final.
 If the coroner receives a response to the draft recommendation before the findings are finalised, the coroner will make reference to the response in the findings.
Judge Deborah Marshall
Dated: 21 July 2016
1 'Immediate family' is defined in section 9 of the Act.
2 'Interested party' is defined in section 9 of the Coroners Act 2006.
3 Section 81 requires the Coroner to give notice of the time, date and place of the inquest to the parties specified in section 23 no less than 10 working days before the inquest.
4 Section 79(3) of the Act.
5 Section 87 of the Act.
6 Also known as a 'hot tub.'
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