Nature of the inquest

The enquiry is directed exclusively to establishing who the deceased was, and how, when, and where he or she came by his or her death. 'How' is to be interpreted as 'by what means' not 'in what circumstances'. The coroner has power to disallow questions which, in his or her opinion, are not relevant to the enquiry, but defining the boundaries of relevance when standards of care may be deficient is far from easy. It is usual for the coroner to ask questions of each witness followed by 'interested parties' or their legal representatives, often counsel or solicitor acting for the bereaved family. At the end of the hearing, the coroner makes a formal record, the 'inquisition'. It includes the verdict which, strictly, is the entirety of the written report, although the term is often used to signify only the conclusion of the coroner or jury as to the death. A list of suggested conclusions is available which includes natural causes, accident or misadventure, and 'open verdict'; the last of these indicates that the evidence is still inconclusive. The consensus of opinion today is that accident and misadventure should be regarded as synonymous, and it is common for such a term to be chosen when an unexpected complication (iatrogenic or otherwise) occurs during medical care. It has no significance as to civil liability.

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