What is the purpose of an inquest?

Coroners are independent judicial officers who work within a legal framework established by Act of Parliament. A coroner’s inquest is a process for investigating the factual circumstances of a death. It is a fact-finding process to establish the answers to: who the deceased was and how, when and where they came by their death.

The proceedings and evidence are directed solely at ascertaining the answers to these questions. Expressions of opinion on any other matter – for example, determining criminal or civil liability – are not permitted. An inquest does not deal with issues of blame or responsibility or with issues of criminal or civil liability.

However, the coroner does have the power to investigate not just the main cause of death, but also “any acts or omissions which directly led to the cause of death”. See ‘Role of a Coroner’.

Where are the hearings being held?

The hearings are held at Guildhall, Gresham Street, London, EC2V 7HH.

When will the hearing start?

The substantive hearings will commence on 12 April 2021.

Please see News for updates.

Do media have access?

Yes. Inquests are open to the public and to the media. Attendance at the Inquests for media is on a ticketed basis only. Any enquiries from the media should be sent to press@fishmongershallinquests.co.uk.

Those attending the Inquests should note that the courtroom is subject to the same restrictions as would apply to normal court proceedings. This means that, when the court is sitting, the use of mobile telephones, other communications or recording equipment, cameras and personal stereos is strictly prohibited.

Cameras cannot be brought into the Guildhall.

For further information please see Chief Coroner Guidance No. 25 – Coroners and the media.

Do the public have access?


Taking into account the Government guidance regarding Covid-19, the Inquests are operating with limited public attendance in person.

Any member of the public who would like to attend the Inquests in person should email generalenquiries@fishmongershallinquests.co.uk and provide details of the day or days they would like to attend. The booking is on a first come first served basis and once that day’s allocation is full, no further requests can be accepted. There will be one seat available for members of the public which cannot be booked and will be available on the day, again on a first come, first served basis.

Those attending the inquests should note that the courtroom is subject to the same restrictions as would apply to normal court proceedings.

Please note that security searches are in operation at Guildhall. Members of the public are not permitted to bring in cameras, large bags, recording equipment, sharp objects, and food and drink into the court room and there are no facilities for such items to be left. Access will be denied if you attempt to bring such items into the Court.

In advance of attending the Inquests, please read the General Information on Covid-19.

Are transcripts of proceedings and evidence made public?

Transcripts of each hearing will be published on this website.

Who is conducting the inquests?

His Honour Judge Mark Lucraft QC.

Who can be called to give evidence?

The Coroner is solely responsible for deciding who should give evidence to the Inquests. Where appropriate, the Coroner may take the views of the Interested Persons in advance.

People may be called upon to give evidence if they can provide relevant information relating to the issues to be determined by the inquests.

Can witnesses be compelled to attend or provide evidence for an inquest?

The Coroner can compel witnesses to give evidence if they are within the jurisdiction and are properly summonsed. If witnesses are outside the jurisdiction the Coroner can ask the authorities concerned to exercise their powers, which may vary according to the relevant jurisdiction.

What are the possible outcomes of an inquest?

After hearing the evidence at an inquest into a death, the coroner or jury (if there is one) must make certain determinations and findings (see section 10 of the Coroners and Justice Act 2009 and rule 34 of the Coroners (Inquests) Rules 2013). In respect of the question ‘how’ the deceased came by his or her death, the possible short-form conclusions which are available to a coroner or jury include the following:

  • Accident or misadventure;
  • Lawful / unlawful killing;
  • Natural causes; or
  • Open (where the evidence did not fully or further disclose the means whereby the cause of death arose).

As an alternative, or in addition to one of the above ‘short-form’ conclusions the coroner or jury may make a brief narrative conclusion.

Where a coroner has conducted an inquest and anything revealed by the investigation gives rise to a concern that circumstances creating a risk that other deaths will occur, or will continue to exist, in the future, and in the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances, the coroner must report the matter to a person who the coroner believes may have power to take such action. A person to whom a coroner makes such a report must give the coroner a written response to it.

Who can take part and be represented in an inquest?

There is an automatic right to “interested person” status for a number of people including the family of the deceased, under Section 47 of the Coroners and Justice Act 2009.

An ‘Interested Person’ is defined as meaning:

  • A spouse, civil partner, partner, parent, child, brother, sister, grandparent, grandchild, child of a brother or sister, stepfather, stepmother, half-brother or half-sister;
  • A personal representative of the deceased;
  • A medical examiner exercising functions in relation to the death of the deceased;
  • A beneficiary under a policy of insurance issued on the life of the deceased;
  • The insurer who issued such a policy of insurance;
  • A person who may by any act or omission have caused or contributed to the death of the deceased, or whose employee or agent may have done so;
  • In a case where the death may have been caused by (i) an injury received in the course of an employment, or (ii) a disease prescribed under section 108 of the Social Security Contributions and Benefits Act 1992, a representative of a trade union of which the deceased was a member at the time of death;
  • A person appointed by, or representative of, an enforcing authority (i.e. including the Health and Safety Executive);
  • In certain circumstances, a Chief Constable, a Provost Marshal and / or the Independent Office for Police Complaints;
  • A person appointed by a Government department to attend an inquest into the death or to assist in, or provide evidence for the purposes of, an investigation into the death under this Part; and
  • Any other person who the senior coroner thinks has a sufficient interest.

A list of the interested persons of these Inquests can be found here.

Will there be a jury?

The Coroner has directed that the Inquests into the deaths of Saskia Jones, Jack Merritt and Usman Khan will be conducted with a jury.