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The Coroner’s statement when opening the inquest included the following -
The purpose of an inquest is limited. It is to find answers to four important but limited questions. It is carried out by a coroner who is an independent judicial officer established by act of Parliament. His responsibility is centred on the body of the deceased person. His authority arises from the physical presence of that body in his district even if it is subsequently removed from it and his focus thereafter is, initially at least, also on the body and the medical cause of death. The inquest thereafter is gradually widened into what events or disease processes gave rise to that medical cause of death. The coroner works outward from the body of the deceased person as the central or starting point.
The inquest that the coroner undertakes receives or hears evidence relating to the body of the deceased person. It relies upon witnesses giving evidence, either sworn evidence, which can be tested and challenged, or documentary evidence. It is a long-established, tried and tested process for investigating the factual circumstances of a death and is fundamentally different in nature and scope to the well-understood adversarial system which we see applied in our criminal and civil courts.
5. In an inquest there is no prosecution and no defence, but rather a single search for the truth. Unlike other English Courts, the inquest does not depend upon a particular proposition or claim being made or argued for, and then challenged. Instead, at an inquest the evidence is considered and then from that evidence a proven chain of causation is drawn ending with the demonstrable medical cause of death.
6. An inquest is not a public inquiry which works to terms of reference drafted to address the specific circumstances under consideration. Nor is it a rubber-stamping exercise. Its single-minded aim is to find the answers to the questions - who the deceased person was, and how, when and where the cause of death arose. The conclusion or verdict at an inquest has to be based upon the evidence as proved, not on speculation.3 Expressions of opinion on any other matter - for example, on who might be to blame - are not allowed4 although actions, based on the evidence thrown up by the inquest, may sometimes be taken in the criminal or civil courts where matters of liability can be addressed.
7. When answering the question " how ... the cause of death arose ", we are told by Sir Thomas Bingham, Master of the Rolls, sitting in the Court of Appeal in 1994, that "'how' is to be understood as meaning ‘by what means'. It is noteworthy that the task is not to ascertain how the deceased died, which might raise general and far-reaching issues, but ‘how .... the deceased came by his death', a more limited question directed to the means by which the deceased came by his death ".
8. About 20 years ago, Lord Lane described the coroner's inquest in these terms - " A coroner's task ... is a formidable one, and no one would dispute that; that is quite apart from the difficulties which inevitably arise when feelings are running high and the spectators are emotionally involved and vocal. Once again it should not be forgotten that an inquest is a fact-finding investigation and not a method of apportioning guilt. The procedure and rules of evidence which are suitable for one are unsuitable for the other. In an inquest it should never be forgotten that there are no parties, there is no indictment, there is no prosecution, there is no defence, there is no trial, simply an attempt to establish facts. It is an inquisitorial process, a process of investigation, quite unlike a trial where the prosecutor accuses and the accused defends, the judge holding the balance or the ring, whichever metaphor one chooses to use. "
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