Resources for practising in the Coroners’ Court

These resources are for CILEX Advocates who practise in inquests in the Coroners’ Courts. They are also useful for members of the public who would like to know more about inquests and the standards we expect of CILEX Advocates who practise in them.

About these resources

CILEX Advocates must always provide a competent standard of service and keep their professional knowledge and skills up to date.

CILEx Regulation have worked with the Bar Standards Board and Solicitors Regulation Authority to develop competences to help CILEX Advocates and the public to understand the standard we expect when practising in the Coroners’ Court. These resources can be used to identify and address learning and development needs and to help CILEX Advocates meet the challenges of practising in the Coroners’ Courts.

The competences and resources have been developed with the assistance of other practitioners (barristers, solicitors and chartered legal executives), coroners including the Chief Coroner and his office, the Deputy Chief Coroner and Senior Coroner for Sunderland, bereaved people who have been involved in inquests, organisations that provide specialist support and in collaboration with the Ministry of Justice and other regulators.

The Competences

This section outlines the competences that we expect from CILEX Advocates practising in the Coroners’ Courts. They can be used to help you identify whether you are meeting the standards we expect, and if not, where you should focus your learning and development.

The competences and resources reflect the main challenges of practising in inquests:

• procedural knowledge
• dealing with vulnerability
• communication and engagement
• working with other organisations.

Procedure

You should:

• Keep your knowledge and understanding of the jurisdiction and procedure of the Coroner’s Court up to date and apply it effectively.
• Assist the coroner in the disclosure of all facts relevant to the inquisitorial process, regardless of who you represent, whilst being mindful of your duty to their clients.

Dealing with vulnerability

You should:

• Recognise the central role of bereaved families and have knowledge and understanding of their vulnerability during an inquest.
• Have knowledge and understanding of the potential vulnerability of interested persons and witnesses during an inquest.
• Adapt the delivery of your service to the needs of such vulnerable people.
• Make sure that those being represented understand the jurisdiction and procedure of the Coroner’s Court and manage their expectations sensitively.

Communication and engagement

You should:

• Speak clearly and concisely, using plain language, especially when communicating with those who are vulnerable.
• Recognise that an inquest is an inquisitorial and fact-finding exercise, and your style of questioning must be appropriate. In particular, recognise that whilst firm and robust questioning may sometimes be necessary, an aggressive and hostile style of questioning is not appropriate.
• Adapt your style of advocacy and personal interactions to the circumstances and potential vulnerability of those participating in the inquest, demonstrating empathy as appropriate.
• Restrict questions to those that are relevant to the purposes of the inquest.
• Be respectful and professional at all times, both inside and outside the courtroom.

Awareness of key organisations

You should:

• Understand how organisations and agencies relevant to the Coroner’s Court can assist and support family members, witnesses and other interested persons.
• Work with relevant organisations and agencies as appropriate, where it will benefit family members, witnesses and other interested persons.

Communication and Engagement

This section explains how you can make sure that you communicate and engage effectively with people who are involved in inquests. The key things to remember are to:

• adapt your style of communication and engagement to the purpose of inquests;
• think carefully about how you communicate and engage with your client(s) and/or vulnerable people involved in the inquest;
• make sure that your client(s) and/or others understand the purpose of the inquest and their role within it; and
• identify and address your learning and development needs.

Why effective communication and engagement are important

Unlike most court proceedings, inquests do not decide responsibility or guilt, because they are limited to finding out the facts of a person’s death. This important difference means that you need to adapt your style of communication and engagement to the purpose of inquests. In doing so, you should think carefully about whether the style of advocacy and questioning that you use in other court proceedings would be appropriate to use in an inquest.

When you take part in inquests, you also need to think carefully about how you communicate and engage with vulnerable people. Vulnerability comes in many forms. Bereaved families, who play a central role in inquests, are often vulnerable because they have lost a relative or loved one. They might also be unfamiliar with the inquest process and not have a lawyer to represent them, even if the other people involved are represented. They might have experienced other processes such as ombudsman investigations or criminal proceedings into the death of their loved one and not understand how the inquest process differs from those other court proceedings. Other Interested Persons or witnesses may also be vulnerable. For example, as a result of seeing a person’s death, witnessing an incident or a staff member of an organisation where the person died.

You should be aware of the trauma that bereavement can cause, which may be persistent and ongoing, and alert to the risks of re-traumatising bereaved people or compounding their grief.  For example, by questioning or engaging with them in an inappropriate, disrespectful, insensitive or clumsy manner.

Thinking about how you communicate with vulnerable people in an inquest can help you to:

• make sure that they understand the purpose of the inquest and their role within it;
• assist the Coroner in making sure that the inquest runs smoothly;
• identify any adaptations that need to be considered by you or the court; and
• meet the standards of competence that you are required to deliver.

You should also think about your behaviour outside court, as it may have an impact on the people who take part in an inquest. For example, members of a bereaved family could be upset if they overheard informal or inappropriate conversations between lawyers.

How you can communicate and engage effectively in inquests

You can use the resources below to help you to communicate and engage effectively during an inquest.

Preparation

• do you have a good understanding of the purpose and circumstances of the inquest, including the possible vulnerability of the people who are involved?
• have you managed your client’s expectations by making sure they understand the purpose of the inquest, their role within it and what they can expect from you? You should consider whether it would be helpful to signpost your client to resources that explain the inquest process and our competences. Doing this may help you to build trust with your client(s).
• have you engaged with other parties to the inquest in advance of the inquest, if it would help the inquest to run smoothly?
• have you adequately considered the risk of re-traumatising bereaved people through the way you question or engage with them and adapted your style of questioning or engagement accordingly?
• are you aware of any issues that should be raised with the court in advance of the inquest, for example, any issues relating to your client(s) or witnesses, to ensure that the process runs smoothly?
• are you missing any useful information, knowledge, or skills which you can acquire before the inquest? For example, is there any training you might benefit from that will help you as a practitioner in the Coroners’ Courts?

Delivery

• do you use plain language to make points and ask questions in a clear and simple way, so that the people involved in the inquest can understand them?

• do you avoid the use of idioms and unnecessary legal jargon or terminology or explain what it means if necessary?
• do you repeat, explain, or rephrase your questions or points if they are not understood by the people taking part in the inquest?
• do you refrain from using inappropriate emotional language?
• are your questions and submissions relevant to the purpose of the inquest and appropriate? For example, questions to vulnerable witnesses, children and people suffering grief are likely to be different to questions to experts such as pathologists.
• are you adapting your questions and submissions to the circumstances and possible vulnerability of the people involved in the inquest? For example, challenges to evidence and the appropriateness of conduct may be required but this should be proportionate to the nature of the issues in the individual inquest and take account of both family and witness vulnerabilities.
• avoid duplication of areas covered by the Coroner by making sure that your questioning either explores areas not raised by them or address details / factual aspects that are different / go further than the areas covered in their questioning.

Working with other organisations

The Coroner’s Court competences require CILEX Advocates to be aware of the organisations offering provide advice and support to family members, witnesses, and other interested persons, and to work with such organisations as appropriate. You should signpost or make a referral to those organisations if it would benefit your client and help to make sure that an inquest runs smoothly.

The following organisations were involved in the development of our competences and resources for CILEX Advocates practising in inquests in the Coroners’ Courts:

• The Coroners’ Court Support Service is an independent voluntary organisation, which provides practical and emotional support to bereaved families, other interested parties and witnesses who take part in inquests. Its trained volunteers run a confidential telephone support service and provide in person support in the Coroners’ Courts.
• Inquest is a charity which gives expert support on state related deaths to a range of people including bereaved people and lawyers. It provides useful resources and free, independent advice on the inquest process for state related deaths.

Here are some other organisations which provide support to bereaved people.

• Action against Medical Accidents provides support to people who are involved in an inquest into a death following medical treatment, including an information leaflet.
• Child Bereavement Charity runs a helpline and has a range of resources for families who have experienced the death of a child.
• CRUSE Bereavement Care provides support to bereaved people, including a helpline and a number of local branches.
• The Good Grief Trust aims to help bereaved people by bringing together all of the bereavement support services that exist in the country in one place.
• Survivors of Bereavement by Suicide (SOBS) provides a range of services for people who are bereaved as a result of suicide including support groups, a helpline and email support.
• The Compassionate Friends offers support services, including a helpline, to people who are grieving the loss of a child.
• Winston’s Wish provides information and support services to grieving children.
• Samaritans can help anyone who is experiencing a difficult time and in need of support, including bereaved people.
• The Centre for Military Justice is a charity providing free legal services to serving or former members of the Armed Forces or their bereaved families.
• Addiction Family Support (formerly DrugFam) provides help to people affected by a loved one’s harmful use of alcohol, drugs or gambling.​
• Brake supports people bereaved and seriously injured by road crashes.
• Disaster Action provides support, advice and guidance for the bereaved and survivors of major disasters.
• Gambling with Lives is a charity providing support to those affected by a loved one’s gambling-related suicide.
• RoadPeace provides information and support services to people bereaved or seriously injured in road crashes.
• Sands seeks to reduce the number of babies dying and supports those affected by the death of a baby before, during or shortly after birth.
• SUDC UK is a charity that provides information and support relating to sudden unexplained death in childhood.
• Support after Murder and Manslaughter (SAMM) provides a wide range of peer support services to people bereaved by murder and manslaughter.
• Support After Suicide Partnership has online resources for those affected by suicide and supports a wide range of organisations to adopt best practices in suicide bereavement service provision.
• The War Widows Association campaigns to improve the lives of war widows and widowers.
• Local Councils: bereavement services offered by local authorities can be found here.

Additional sources of information for witnesses

Some organisations provide information, guidance and advice specifically for people who are called to give evidence to inquests in a professional capacity.  Resources for witnesses include the following:

• Academy of Medical Royal Colleges guidance for healthcare professionals on acting as an expert or professional witness.
• General Medical Council guidance on providing witness statements or expert evidence as part of legal proceedings.
• Health and Safety Executive guidance on work-related deaths and inquests.
• NHS England provides advice and guidance for trainee doctors who are required to engage with Coroners’ Inquests.
• NHS Resolution guide for health providers called to give evidence at inquests.
• Royal College of Nursing advice guide for health care staff called to give evidence at Coroners’ Inquests and other investigations.
• Royal College of Psychiatrists guides and resources to support mental health professionals following the death of a patient by suicide.
• The University of Plymouth has created a series of videos and other information providing tips and advice for medical witnesses at inquests.

Keeping your knowledge up to date

It is important that CILEX Advocates always provide a competent standard of service and keep their professional knowledge and skills up to date. Continuing Professional Development (CPD) is a professional requirement which will help you to keep your knowledge and skills current so that you can deliver the high quality of service that safeguards the public and meets the expectations of clients, as well as your regulatory requirements.

Resources

This section is designed to help you keep the knowledge and skills that you need to practise effectively in inquests up to date. The key things to remember are:

• reflect on your knowledge and skills on a regular, ongoing basis to identify any learning and development needs.
• address your learning and development needs to make sure that you are competent to practise.

You can also use the following resources to help you reflect on your competence to practise effectively in inquests. They should be used alongside the specific competences and resources for those who practise in inquests:

• The Office of the Chief Coroner maintains a range of resources including guidance and general advice from the Chief Coroner, a summary of key cases, annual reports and FAQs.
• The Ministry of Justice ‘Guide for Coroner Services for Bereaved People’ gives a detailed overview of the purpose of inquests and the different stages of the inquest process. It is useful for anyone involved in inquests, including lawyers.
• The Coroners’ Society of England and Wales regularly updates the announcements section of its website and has a section of links to important external organisations and resources.
• The Advocates’ Gateway has a wide range of free toolkits to help lawyers to communicate and engage effectively with vulnerable people during court proceedings.
• Advocacy and the Vulnerable is a national training programme for lawyers who engage with vulnerable people during court proceedings. The training is endorsed by The Law Society and can be booked through its website. The training includes an online course, virtual classroom-based training and a reflection element.
• Chapter 2 of the Equal Treatment Bench Book includes useful and practical information about how lawyers should adapt their style of advocacy and questioning when dealing with people who are vulnerable.
• Judiciary.uk provides general information about coroners and inquests, including a list of coroner areas and senior coroner appointments.
• Gov.uk has a step by step guide on what to do when someone dies.
• Gov.uk has Guidance on legal advice or representation at inquests at inquests, including how to access legal aid funding.
• Coroners appointments and instructions on how to contact their offices can be found here.
• The House of Commons Library can be searched for research briefings relating to the Coroners’ Courts.
• NHS England information on the national medical examiner system includes contact information for national and regional medical examiner offices.
• Human Tissue Authority information on post-mortem examinations for those who are bereaved and affected by a post-mortem examination.
• The Preventable Deaths Tracker is an open, searchable database of all published coroner Prevention of Future Deaths Reports.

The following questions can help you identify whether you have any gaps in your legal knowledge about the Coroner’s Court. You should address any gaps by undertaking learning and development.

• do you have good knowledge of case law, legislation, and relevant guidance on inquests?
• do you understand how to communicate and engage effectively with vulnerable people before, during and after an inquest?
• do you understand how to adapt the style of your advocacy and questioning to inquests?
• do you understand how to adapt the style of your advocacy and questioning to vulnerable people?
• are you aware of the organisations and forms of support which exist to help people taking part in inquests?

Possible training options

Several organisations provide useful resources and training on the areas covered by the Coroner’s Court competencies.  The following is not a list of recommended providers but simply, possible options.  Some are directed at professionals working the coronial system more broadly and are not targeted specifically at legal practitioners.  It is not an exhaustive list and will be updated from time to time.

• SLD Training offers Coroners’ Courts Training
• The Maudsley Learning Coroner’s Court course is aimed at those working in mental health.
• MBL runs seminars on Inquests and Coronial Law.

How to report a concern about a CILEX Advocate’s performance in an inquest

If your concern arises during an inquest, it may be appropriate for you to raise it directly with the coroner in charge.  Coroners are aware of the standards that CILEX Advocates should provide and may be able to resolve the issues quickly.

How to report concerns to CILEx Regulation

If you have concerns about a CILEx Advocate’s conduct in Coroners’ Court proceedings and think they may have failed to meet the Coroners’ Courts Competencies or a requirement in the CILEX Code of Conduct, please refer to the Problems and Complaints page on our website.

Please do note that all reports received are dealt with confidentially, so CILEx Regulation is therefore unable to comment on an ongoing investigation.