§ GUIDE · INQUESTS

An inquest cannot
find anyone negligent

Families come to an inquest expecting it to say whether the hospital was at fault. By law it cannot. A coroner is forbidden from framing a finding so that it appears to decide civil liability, and words like negligence and breach of duty are not allowed. Understanding what an inquest is actually for changes what you get out of it, and it matters for a claim.

Questions answered

Four

Standard of proof

Civil standard

Average to conclusion

About 7 months

Coroner reports 2025

654

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§ BEFORE YOU GO FURTHER

If a relative died and there is an inquest, these are the things to know first

  • The inquest answers four questions: who died, and how, when and where. It does not decide fault.
  • You are almost certainly an interested person, which gives you the right to see the documents and to question the witnesses.
  • The three-year time limit for a claim runs from the death, not from the inquest. Waiting for the inquest can run the clock down.
  • The coroner's conclusion cannot be used as proof in a later claim, but the evidence given at the inquest can be.

This page covers England and Wales. Scotland has no inquests: deaths are investigated by the Procurator Fiscal, with a Fatal Accident Inquiry in some cases, and different time limits apply.

§ 01

What an inquest is for

A coroner must investigate where there is reason to suspect a violent or unnatural death, a cause of death that is unknown, or a death in state detention. A death during medical treatment is one of the situations a doctor must report. The investigation then has one statutory purpose: to establish who the deceased was, and how, when and where they came by their death.

In an ordinary hospital inquest, how means by what means, that is the medical mechanism. In a narrower class of case the question expands to the circumstances as well, but the Supreme Court confirmed in 2023 that ordinary medical negligence in an NHS hospital does not trigger that wider inquiry, because the family already has the option of a civil claim.

§ 02

The line the coroner cannot cross

The Coroners and Justice Act says a determination may not be framed so as to appear to determine any question of civil liability. For criminal liability the bar applies to naming a person; for civil liability it is absolute. Chief Coroner guidance spells out the consequence: a coroner may say that something caused or contributed to a death, but may not use the words negligence, breach of duty or careless.

So a coroner can find that a scan was not requested, that a deterioration was not escalated, that a drug was not given, and that those things contributed to the death. What the coroner cannot do is attach the legal label. That is the civil court's job, and only the civil court's.

Two things follow that families often get wrong. A conclusion of natural causes does not mean nobody was at fault; it describes the medical mechanism. And a conclusion that stops short of criticism does not mean a claim is weak, because the coroner was constrained in a way the civil court is not.

§ 03

Neglect at an inquest is not negligence

Neglect is not a conclusion in its own right. It can be added to one, and it means something much narrower and harder than negligence: a gross failure to provide basic medical attention to someone in a dependent position, with a clear and direct causal connection to the death. It is about basic checks not being done, not about whether complex treatment was correct.

The practical consequence is counter-intuitive. A family whose case falls well short of neglect may still have a strong negligence claim, because the civil test is easier to meet. A finding of neglect, on the other hand, is a powerful sign.

§ 04

What you are entitled to as an interested person

Close family are interested persons automatically, and so is any organisation whose act or omission may have contributed to the death, which is how the trust ends up in the room. Interested persons can ask for the documents the coroner holds, including post-mortem and expert reports, and the coroner must provide them as soon as reasonably practicable. You also have the right to question any witness, yourself or through a representative.

That is the real value of an inquest to a family. Clinicians give evidence on oath, are questioned, and do so far earlier than they would in civil proceedings, while memories are fresher. Legal aid for representation at an inquest is limited and normally requires an exceptional case application, so many families are unrepresented while the trust has a barrister.

§ 05

The time limit does not wait for the inquest

This is the most important practical point on this page. The three-year period for a fatal claim runs from the date of death, or the date the family knew enough to investigate, whichever is later. An inquest does not pause it. Inquests took an average of about seven months to conclude in 2025 and nearly one in five took over a year.

There is a further trap. If the person who died was already out of time to bring their own claim before they died, the dependency claim cannot be brought at all, and the court's discretion to forgive lateness does not apply to that question. Take advice during the inquest process, not after it.

§ 06

Using the inquest in a claim

The coroner's conclusion itself is not admissible as proof of the facts in a later civil claim. That is a long-standing rule, and it cuts both ways: an unhelpful conclusion is equally inadmissible against the family. What is usable is the material, including the recording of the hearing, the trust's internal reports and any expert evidence disclosed, though a coroner can restrict how documents are used.

Prevention of Future Death reports are the one place a coroner is allowed to say what should change. The organisation must respond in writing within 56 days, and both the report and the response are published. There were 654 such reports in 2025. We have read the most recent 72 concerning hospital deaths, and the same failures recur: sepsis not escalated, results not reviewed, falls, and patients left in departments with no bed.

§ THE JUDGMENTS BEHIND THIS GUIDE

Judgments where a death led to a civil claim.

Published decisions of the courts of England and Wales, linked to their source. These are civil claims, not inquests, and they show what the civil court decides that a coroner cannot.

Claimant succeeded£340,000

Bayless & Ors v Norfolk and Norwich University Hospitals NHS Foundation Trust

[2023] EWHC 2986 (KB)·2023·Liability decided at trial

The Trust admitted it missed an aortic dissection that emergency surgery would probably have cured, and settled the fatal claim for £340,000. When the widow and children later sued for psychiatric injury from witnessing the death, the Trust tried to strike that out but withdrew after discovering the earlier settlement had never been court-approved.

Fatal claims involving children need court approval of any settlement or it may not bind them. A missed aortic dissection in a chest-pain patient was accepted as negligent and fatal.

Claimant succeeded£119,048

Taaffe v East of England Ambulance Service NHS Trust

[2012] EWHC 1335 (QB)·2012·Liability and damages decided at trial

Paramedics attended Mrs Taaffe for severe chest pain, found it had subsided, took two ECGs (one flagged by the machine as abnormal) and left her to see her GP the next day; she died of a heart attack five days later. The judge found the paramedics failed to take a proper history or assess her risk factors and should have advised hospital attendance, where her condition would have been found and treated.

Ambulance crews owe a duty to take a proper history and weigh risk factors, not just current symptoms, before deciding not to convey a chest-pain patient. Where hospital assessment would have prevented the death, the ambulance trust is liable.

Claimant succeeded£75,000

Henderson v The Hillingdon Hospital NHS Foundation Trust

[2018] EWHC 3281 (QB)·2018·Liability decided at trial

Mr Bolton, 77, was brought to A&E by ambulance in respiratory failure and distress; after nebulised treatment he improved and the A&E doctor sent him home with antibiotics, without properly considering the paramedic and triage records. He collapsed at home hours later with an obstructed airway and died; the judge found he should have been admitted and awarded the agreed £75,000.

An A&E doctor must take account of the full picture, including paramedic and triage records, before discharging a patient who arrived in respiratory failure. Improvement after treatment does not make discharge safe if the underlying cause has not been identified.

Claimant succeeded

Marshall v Schembri

[2019] EWHC 283 (QB)·2019·Liability decided at trial

A woman with a previous pulmonary embolism saw her GP with chest pain and breathlessness and was diagnosed with a strained muscle; she died the next morning. The GP admitted he should have referred her to hospital, and Stewart J found she would on the clear balance of probabilities have survived with anticoagulation and monitoring.

Chest pain and breathlessness in someone with a past clot is a red flag needing same-day hospital referral. Where survival chances on admission would have been very high, the court will find the death was caused by the failure to refer.

Claimant succeeded£1.2M

Healey v McGrath & Anor

[2024] EWHC 1360 (KB)·2024·Liability decided at trial

Mr Healey died nine days after bowel cancer surgery at a private hospital when a leak at the surgical join was not recognised in time. The hospital settled the widow's claim for £1.2 million and the court ordered the surgeon to bear 75% of it, finding his failure to diagnose the leak the principal cause of death.

Post-operative deterioration after bowel surgery must prompt urgent consideration of a leak. Both the private hospital and the individual surgeon can be liable, with the court apportioning responsibility between them.

Claimant succeeded

Shaw v Maguire

[2023] EWHC 2155 (KB)·2023·Liability decided at trial

A skin sample taken in 2007 was reported as benign but in fact showed melanoma, which was only picked up in 2009 and caused the patient's death in 2014. His widow issued proceedings over five years late after her first solicitors let the case drift, and the court allowed the claim to proceed.

The clock can start later than the mistake itself, because it only runs once you know the injury is serious. Delay caused by former solicitors rather than by the claimant is far less likely to defeat a late claim, especially where the original slides and reports survive.

Claim failed

Callaghan v South Tees Hospitals NHS Foundation Trust

[2023] EWHC 1199 (KB)·2023·Liability decided at trial

A baby born at James Cook University Hospital was discharged two days after birth and died of GBS meningitis and sepsis. The judge found only one limited breach (a missing piece of discharge advice) and that it did not cause the death because the mother would not have returned to hospital in time.

Even where a hospital gets something wrong, the claim fails unless the mistake is shown to have changed what happened. Record-keeping failings alone did not establish causation here.

Claim failed

Paul and another v Royal Wolverhampton NHS Trust; Polmear and another v Royal Cornwall Hospitals NHS Trust; Purchase v Ahmed

[2024] UKSC 1·2024·Appeal decision

Three families sought damages for psychiatric injury after watching a relative die from a condition that doctors had negligently failed to diagnose. The Supreme Court (Lord Burrows dissenting) held that doctors do not owe relatives a duty to protect them from the shock of witnessing a patient's death or medical crisis.

Relatives who develop a psychiatric illness from witnessing a loved one's death caused by medical negligence generally cannot claim as secondary victims. Their remedies are limited to the Fatal Accidents Act dependency and bereavement claims.

Browse the whole case library →

Contains information licensed under the Open Justice - Licence v2.0. Judgments from Find Case Law, The National Archives. Summaries are ours; amounts only where printed in the judgment.

§ QUESTIONS

Common questions

Will the inquest tell us whether the hospital was negligent?

No, and it is not allowed to. The law says a coroner's determination cannot be framed so as to appear to decide civil liability, and guidance forbids words like negligence and breach of duty. It can find the facts, which is often what a claim is built on.

The conclusion was natural causes. Does that end it?

No. Natural causes describes the medical mechanism of death, not the standard of care. Several claims in our library succeeded where the immediate cause of death was a natural process that better care would have prevented.

Should we wait for the inquest before seeing a solicitor?

No. The three-year limit runs from the death, not the inquest, and inquests average around seven months with nearly a fifth taking over a year. Take advice during the process so the deadline is protected.

Can we use what was said at the inquest?

The coroner's conclusion cannot be used as proof, but the evidence can: the recording of the hearing, disclosed records, the trust's own investigation and any expert reports. Check whether the coroner restricted how documents may be used.

Can we get legal aid for the inquest?

It is limited. Representation normally requires an exceptional case application, and after a 2023 Supreme Court decision ordinary NHS negligence deaths do not usually qualify on human rights grounds. Ask a solicitor early, because the position has been under review.

Is this the same in Scotland?

No. Scotland has no inquests. Deaths are investigated by the Procurator Fiscal and some lead to a Fatal Accident Inquiry, under different legislation and different time limits.

This guide is general information about the law in England and Wales, not legal advice about your case. ClaimGavel is run by Costart Projects Ltd on behalf of Tomlin & Partners, a specialist medical negligence firm regulated by the SRA. The free assessment on this page is an AI overview to show you roughly where you stand; a solicitor confirms the position in a free, no-obligation conversation.