Introduction by Rebecca Omonira-Oyekanmi and Clare Sambrook

Every inquest held when someone dies in the state's care or custody deserves proper scrutiny. But many go unreported. Sometimes the only observers are from the bereaved family. If the family is unable to attend (perhaps they live in another country, far away), it may be that no observers are present.

Here at Shine A Light we have for years reported on inquests that might otherwise escape public scrutiny, including 20 detailed reports (2014 to 2016) from otherwise ignored or under-reported inquests into the deaths of detained migrant men: Bruno Dos Santos, Alois Dvorzak and Brian Dalrymple. In the summer of 2018, we covered every day of the inquest into the death in police custody of young Black Londoner Rashan Charles. And in the winter of 2019 we attended the inquest of Carlington Spencer, a 38 year old Jamaican man who was left for more than 12 hours after suffering a stroke in immigration detention, despite his friends alerting detention centre staff about his condition. He died in hospital four days later.

Inquests offer an opportunity to hold the state to account, to identify poor policy and dangerous practice. Police officers, immigration guards, medical practitioners and others might be questioned on the events that led up to a person's death.

The coroner, who presides over the inquest, is obliged to issue a report with recommendations for change where an inquest reveals problems that can and should be fixed. The aim is to prevent future deaths, to avoid fatalities that are avoidable. Inquests can provoke change that saves lives.

But, as with any democratic or judicial process, integrity of process varies. The quality and integrity of coroners, pathologists, varies. The quality of forensic questioning might depend on a bereaved family's ability to raise funds to pay for a barrister while agents of the state can invest heavily in legal counsel. There's often a worrying inequality of arms. For a bereaved family, what happens at the inquest can "make a devastating situation even worse".

Scrutiny really matters.

Along with developing our archive of stories exposing state abuse and neglect, we share intelligence and skills with fellow reporters.

Through our Inquest Reporting Project we encourage more of our fellow journalists to pursue early and deep investigation into contentious state-related deaths. In July 2019, in partnership with INQUEST and supported by the Dart Center for Journalism and Trauma Europe, we designed and ran two workshop presentations for journalists. They told us of the need for a go-to guide to inquest reporting.

We were delighted when Dr George Julian agreed to produce this guide. George has attended and reported daily on five inquests into the deaths of learning disabled and autistic people since 2015 (as well as live tweeting a Medical Practitioners Tribunal Service hearing and two court cases). She has developed techniques for live-tweeting proceedings to create a fast and reliable record that the bereaved family, lawyers and journalists can use. She currently holds a grant from the Paul Hamlyn Foundation Ideas and Pioneers Fund to explore the impact of, and future business model to support, her inquest reporting. You can read more of George's thoughts, reflections and tips on live tweeting inquests and tribunals here.

Over to George.

INQUEST REPORTING: FAQs

The type of inquests we’re concerned with here are the court proceedings that come at the end of an investigation into an unnatural or suspicious death. This process is presided over by a coroner with a support team including at least one court clerk. The rules and guidance governing inquests are complex, here we provide a simple guide for people interested in turning up and observing court proceedings.

What is the purpose of an inquest?

Inquests are legal inquiries into the causes and circumstances of a death. They answer four key questions:

• who died,
• where they died,
• when they died,
• and how they came to their death.

It’s within a coroner’s power to expand the question of “how a person came by their death” by asking in addition:

• by what means and in what circumstances a person came by their death.

You might hear this type of investigation referred to as an Article 2 inquest or a “Middleton” inquest (by what means and in what circumstances) or “Jamieson” inquest (by what means).

Which deaths have an inquest?

Inquests are opened when there’s reasonable suspicion a death was violent or unnatural; where the cause of death is unknown; where the person died in custody or otherwise in state detention; when the Chief Coroner directs that there should be an investigation. See Coroners and Justice Act (2009) for more on the duties of a coroner.

What is an Article Two inquest?

Article 2 of the European Convention on Human Rights, the right to life, imposes a duty on the state to protect life. It also requires the state to carry out an effective investigation into a death, involving the family of the deceased, these are known as Article 2 inquests.

An Article 2 inquest has more scope for the coroner or jury to leave critical conclusions on what has happened. Deaths of someone in state detention, such as in prison or policy custody, or a person held under section in psychiatric care, are Article 2 inquests.

Which inquests have a jury?

Inquests must be held without a jury unless the coroner suspects:

• the person died in prison, police custody or otherwise in state detention and the death was violent, unnatural or cause unknown;
• the death resulted from the action or omission of a police officer in the purported execution of their duty;
• the death was caused by a notifiable accident, poisoning or disease;
• the death occurred in circumstances where the continuance or reoccurrence of these circumstances is prejudicial to public health and safety.

A coroner also has discretion to hold an inquest with a jury if they think there is sufficient reason to do so.

What is a ‘Jamieson’ and a ‘Middleton’ inquest?

Jamieson and Middleton refer to case law and both types consider neglect. Jamieson inquests consider whether a lack of care, or common law neglect, has led to the cause of death. Usually heard where death occurred in a medical context or where someone was in police or other custody immediately prior to their death (including death by suicide).

Middleton inquests relate to state involvement in a death. In the Middleton case a jury considered an agent of the State (the Prison Service) had failed in its duty of care to the deceased, who hanged himself in prison while identified as at risk, however proper safeguards weren’t put in place.

Attending an inquest

What’s a senior coroner, area coroner and assistant coroner?

There are 92 coronial jurisdictions, each with a senior coroner appointed by the local authority in which they sit. The senior coroner is in charge of their area and they work alongside full-time employed area coroners and part-time assistant coroners.

Some coroners are medical professionals but the Coroners and Justice Act 2009 states that all newly appointed coroners must be qualified lawyers (solicitors, barristers or legal executives with at least five years’ experience).

What is a coroner’s officer, a listings officer and a court clerk?

A coroner’s officer assists the coroner and serves as liaison between them and bereaved families, they are often retired police officers. Listings officers organise the court diary and court clerks are officers of the court who provide administrative support to the court.

How can I find out about upcoming inquests?

Coroners must give advance warning of inquests, that does require you to check each coroner’s website for information. You can call the coroner's office phone number, which is usually listed on the website.

What are PIRs, or pre-inquest reviews/hearings?

A coroner will often hold at least one and often several pre-inquest reviews or pre-inquest review hearings in complex cases. These are held to assist with inquest preparation. There are no set agendas or procedures for the hearing, but they are held in open court, in the same manner as an inquest. Interested persons attend and may contribute to the discussion.

Are inquests always held in public?

Yes, unless there are exceptional circumstances, usually matters of national security. Public hearings allow members of the public and journalists to attend. Some parts or sections of the inquest could be held in private, if national security would be compromised by the information being in the public domain.

What are the rules around reporting from inquests?

The Chief Coroner has shared guidance for coroners on engaging with the media (Guidance No25). This guidance makes it clear that the starting premise is one of Open Justice:

The only exceptions to this are when the coroner considers matters are of interest to justice or national security. Names of the deceased, interested persons and witnesses (unless granted anonymity) are always given in open court, and therefore to the media.

Where a coroner is considering imposing a reporting restrictions order, the advice is that this should be discussed in the first instance at a PIR, with due notice given to the media (via the Press Association). This is to allow journalists to make representations to the court if they wish.

What can be reported from court?

Coroners can impose reporting restrictions to ensure risks to prejudicing justice are avoided, for example, if the police inform the coroner of reporting restrictions in place as a result of ongoing criminal proceedings.

Coroners have specific powers to prohibit the publication of personal details of young people and children appearing as witnesses.

In the absence of any reporting restriction anything shared in open court can be reported.

Can journalists tweet from court?

Yes, journalists can tweet contemporaneously from court and no application needs to be made to do so (providing no reporting restrictions are in place):

Is an inquest recorded and can I access the recording?

All PIR and inquest hearings must be audio recorded. It is at the coroner’s discretion whether they choose to share a recording with journalists. Members of the media, who can show identification (if requested), should normally be expected to be considered proper persons and their request considered accordingly. Coroners are under no obligation to produce a hearing transcript. A charge of £5 may be made for a copy of the recording.

What about statements, post-mortem reports and other documents referred to in court?

The rules are the same as for recordings. Any document referred to in inquest proceedings, may be shared at the coroner’s discretion. A charge of £5 may be made for a copy of any document.

A coroner need only consider sharing a document with bona fide journalists (identification will help your case) and if it is for a ‘proper journalistic purpose’. It may help your case for access if you can identify to the coroner why you wish to access the document in question, for example, to enable the public to understand and scrutinise the coronial system.

Journalists are not entitled to see documents not referred to in court, even if they have been relied upon and adduced in evidence.

The coroner’s final reports

What is a PFD or Rule 43 report?

The coroner has a duty to make a PFD or Prevention of Future Death report (formerly known as a Rule 43 report) with recommendations to prevent future deaths from occurring, where a concern is identified. Usually this occurs at the end of an inquest, however a PFD report can be made before an inquest is heard if the coroner concludes that there is an urgent need to take action without delay.

A PFD report is a recommendation that actions should be taken, not a specification of what that action should be. The coroner will send to any person (or organisation) who they believe may have power to take action. Respondents have 56 days to reply in writing giving details of the actions that have been taken, or they propose will be taken, or an explanation as to why no action will be taken.

Copies of all PFDs and responses are sent to the Chief Coroner and interested persons. The coroner will consider requests for copies from other persons on a case by case basis. The Chief Coroner’s Guidance states that ‘Coroners should err on the side of openness unless there is a very good reason for restricting access to these documents’ (2013:49).

Where can I find them?

The Chief Coroner publishes PFD reports, with limited redaction, on the coroner’s section of the judiciary website and has done so since July 2013. There is a presumption of publication. You can access the website here: https://www.judiciary.uk/subject/prevention-of-future-deaths/.

Can I search by place of death?

The PFD search facility is somewhat limited and it’s not possible to search directly by place of death. There is a publication filter facility that allows you to limit search results here: https://www.judiciary.uk/publications/. It is possible to search by coroner’s name or deceased person’s name. It is also possible to filter by date.

PFD reports are also categorised and searchable by type of death; some deaths appear in more than one category:

• Accident at Work and Health and Safety related deaths
• Alcohol, drug and medication related deaths
• Care Home Health related deaths
• Child Death (from 2015 onwards)
• Community health care and emergency services related deaths
• Emergency services related deaths (from 2019 onwards)
• Hospital Death (Clinical procedures and medical management) related deaths
• Mental Health related deaths
• Other related deaths
• Police related deaths
• Produce related deaths
• Railway related deaths
• Roads (Highway safety) related deaths
• Service Personnel related deaths
• State Custody related deaths
• Suicide (from 2015 onwards)
• Wales PFDs (from 2019 onwards)

Who else investigates deaths? Can we get copies of their reports?

The police investigate some deaths and an inquest is likely to be adjourned pending the outcome of any criminal proceedings.

Deaths of prisoners or detainees in the custody of the prison and probation service (defined as in prisons, young offenders’ institutions, secure training centres, immigration removal centres, probation approved premises, and in court cells) are investigated by the Prisons and Probation Ombudsman. All fatal incident reports are published online here: https://www.ppo.gov.uk/document/fii-report/. Reports can be filtered by date of death, or date of publication, by location, cause, gender and age. They can also be searched by establishment name.

Deaths of patients in hospitals or in receipt of health services should be investigated if they meet the criteria of a serious incident requiring investigation. Most independent investigations relate to homicides, but occasionally other deaths are investigated. Reports are not easy to find but those published by NHS England should be accessible via the regional pages linked here: https://www.england.nhs.uk/publications/reviews-and-reports/invest-reports/.

Self-care and the emotional impact of reporting inquests 

There are many aspects of reporting inquests that can present emotional challenges and potentially, if not managed well, have an impact on your own wellbeing and mental health. 

Content of inquests 

Inquests by their nature often explore unnatural or violent deaths. Courts will usually hear from a pathologist and detailed exploration of a post mortem report is not uncommon. The court may be played 999 calls, be read suicide notes and be shown traumatic video. Sometimes these details are revisited again and again throughout the course of the inquest. While reporting on a single inquest may cause passing distress, the cumulative impact of reporting from numerous inquests, or similar inquests, should not be underestimated. 

Working with bereaved families 

Depending on the approach you take to reporting an inquest you may develop a relationship with a bereaved family. We have a duty to ensure that we do not cause that family additional trauma. We should also be mindful of the challenge of witnessing the impact of the bereavement, and the inquest process, on family members. 

Working practices

There are a number of challenges to reporting from inquests that may add to the emotional impact of the work. Reporters are often working solo, spending periods of time away from home and spending long days in court. It is rare to have sight of the court documents and statements in advance of the inquest, so contemporaneous reporting requires total attention, and accuracy. The pace of exchange in court is often quick, and it is incredibly draining work. This is in addition to the perennial challenge of poor wifi connectivity and often uncomfortable and inaccessible old court rooms. Reporters are unlikely to be paid to attend more than the opening and/or closing day of an inquest, so there are likely to be financial challenges if you seek to report on an inquest in its entirety. 

Self-care

The Dart Centre for Journalism & Trauma network hosts a wealth of resources that can help journalists to manage their health in reporting inquests, and any potential cumulative impact of doing so. There are resources on: Working with Traumatic Imagery (albeit the strategies are often out of your control in a court setting) and Managing stress and trauma on investigative projects. Guides to reporting on homicide, suicide and intimate partner violence amongst many other topics, where the principles are transferrable to reporting related inquests. Dart also hosts resources linked to PTSD and Mental Health and to Self-Care and Peer Support which are likely to be of use to anyone reporting on inquests, especially in detail.

In summary it is worth acknowledging that there are several potential risks to reporting from inquests, many of which are likely to have a cumulative effect. The more that we can prepare for, acknowledge, and address them, the greater chance we have of staying healthy ourselves.

Resources

Coroners and Justice Act (2009)

Coroners (Inquest) Rules (2013)

Coroners (Investigations) Regulations (2013)

CPS Legal Guidance Coroners

Chief Coroner’s Guidance

Guidance No4 (2013) Recordings

Guidance No5 (2013) Reports to prevent future deaths

Guidance No25 (2016) Coroners and the media

Lord Chief Justice’s Guidance

Practice Guidance: The use of live text-based forms of communication (including Twitter) from court for the purposes of fair and accurate reporting (2011)

INQUEST handbook: a guide for bereaved families, friends and advisors

Judiciary Prevention of Future Deaths database

Legal Action Group practitioner's guide to inquests

Edited by Rebecca Omonira-Oyekanmi for Shine A Light.

Commissioned by Jeanny Gering from the Dart Centre for Journalism and Trauma Europe.