The conclusion of the inquest process

Summing up

When the coroner has heard all the evidence at a resumed inquest hearing, they will summarise the evidence that has been heard for those attending,  this is often called a  ‘summing up’.

Unlike in a civil or criminal trial, the interested person's and their legal representatives do not summarise the evidence or make speeches on what they think the outcome of the inquest should be. However, legal representatives may address the Coroner on the law that should be taken into account when reaching conclusions.

If there is a jury the Coroner will speak to the jury about how they should apply the law when making their decision.

Reaching conclusions

The Coroner, or the jury if there is one, will reach conclusions and provide these to the interested persons at the resumed hearing. These conclusions will usually be composed of findings of fact concerning events that contributed to the death and a legal determination of who died and how, when and where the death occurred.

Before the conclusion is given, the Coroner may adjourn to consider the formulation of the conclusion. 

If there is a jury, the jury members will leave the hearing room to discuss the case in private and agree what their conclusions are before delivering them to the hearing. The Coroner may decide which conclusions are open to the jury. The jury may ask the Coroner questions if they are unclear about something but there will be no further evidence. 

Once the Coroner or the jury have decided what their conclusions are and have delivered these in the inquest hearing then the inquest will close. 

Reports to prevent future deaths

Sometimes an inquest will show that something could be done to prevent similar future deaths.

If the Coroner considers this to be the case then the Coroner may write to bring this to the attention of an organisation or person who may be able to take action to prevent future deaths. This is called a ‘report to prevent future deaths’ or a ‘Rule 12 Report’. If you would like to see a copy of the Rule 12 Report you should let the Coroner know.

Record of inquest

A written record of the inquest is prepared by the Coroner and a copy is provided to the interested persons.

The Coroner reports the conclusions to the Bailiff who orders that they be registered by the Judicial Greffier. After registration, a copy of the conclusions is sent to the Superintendent Registrar so that the death can be registered. The Coroner formally reports the death to the Superintendent Registrar and signs the Register of Deaths to complete this process.

These final processes may take up to 21 days to complete.

More information about obtaining a copy of the entry in the Register of Deaths (usually referred to as a ‘Death Certificate’) has been published by the Superintendent Registrar.