A coroner is an independent judicial office holder. Coroners investigate deaths that have been reported to them if it appears that the death was violent or unnatural, where the cause of death is unknown or where the person died in prison, police custody, or another type of state detention.

Coroners are appointed by and paid by the local authority for their area but they are independent of the local authority and government.

The work of coroners is overseen by the Chief Coroner who is the head of the coronial system, providing national leadership for coroners in England and Wales. The current Chief Coroner is His Honour Judge Mark Lucraft QC.

In particularly complex cases (for example where there are multiple deaths) a judge may be appointed to oversee the inquest. Her Honour Judge Sarah Munro QC has assumed responsibility for these inquests from the Senior Coroner for the East London Area.
An inquest is a fact-finding exercise. The purpose of an inquest is to establish the answers to the four questions posed in section 5 of the Coroners and Justice Act 2009.

These are:
  • who the deceased was;
  • when and where the death occurred;
  • how the deceased came by his or her death; and
  • particulars required by the Registration Acts to be registered concerning the death.

  • If the Coroner decides that Article 2 of the European Convention on Human Rights (as enacted through the Human Rights Act 1998) is engaged, the coroner’s investigation to answer ‘how’ someone died will be wider and consider both by what means and in what circumstances they died.

    It is important to note that the proceedings and evidence are aimed only at determining the answers to these questions and are not a mechanism for apportioning civil or criminal liability against a named individual. If evidence is found, however, that suggests an individual or organisation may be to blame for the death, then a coroner can pass all the evidence gathered to the appropriate authorities.
    The inquests' evidential hearings started in the Barking Town Hall on 5th October 2021. After 38 days of hearings, the Inquests concluded, on schedule, on 10 December 2021 with the Jury's conclusions.
    The hearings were held in the Barking Town Hall.
    The Assistant Coroner directed that the Inquests into the deaths of Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor would be conducted with a jury.
    Yes. Inquests are open to the public and to the media. Media had access and were able to report on the East London Inquests.

    For further information please see Chief Coroner Guidance No. 25 – Coroners and the media.
    Transcripts of hearings were published daily on this website together with, wherever possible, the evidence that was seen and heard during the course of the Inquests.
    A coroner is responsible for deciding who should give evidence in an inquest and may seek the views of Interested Persons before making a decision.

    A witness may be called to give evidence if they can provide material and relevant information on the issues which fall to be considered.

    A coroner has the power to compel witnesses to appear if that becomes necessary and, subject to certain criteria, can read witness evidence.
    After hearing the evidence at an inquest into a death, a 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).

    A determination needs to record formally the answer to the four statutory questions (the identity of the deceased and where, when and how they came by their death). The findings are the details required for registration purposes. The outcome of an inquest is recorded on a Record of Inquest.

    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 may 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).

  • These would be recorded in box 4 of the Record of Inquest. As an alternative, or in addition to one of the above ‘short-form’ conclusions, a coroner or jury may make a brief narrative conclusion.

    Further details about the outcome of an inquest, including law sheets and guidance, can be found on the website of the Office of the Chief Coroner.
    Where a coroner has conducted an inquest, and anything revealed gives rise to concern that circumstances creating a risk of other deaths will occur or continue to exist, then the coroner must report the matter to a person who the coroner believes may have power to take such action.

    Examples of this might be reporting matters to a police force, the Crown Prosecution Service or the Health and Safety Executive (this list is not exhaustive).

    A person or organisation to whom a coroner makes such a report must give the coroner a written response to it within 56 days, or longer if permitted by the coroner.
    An Interested Person is defined in section 47 of the Coroners and Justice Act 2009. A coroner may designate an Interested Person (often shortened to ‘IP’) if they meet the legal test set out in this section.

    Examples of those who may be designated as an Interested Person as of right include a parent, spouse or sibling of a deceased person, the beneficiary of a life insurance policy held by the deceased person or a Chief Constable where the death involves a homicide offence. A coroner may also designate any other person whom they consider has a sufficient interest.

    Interested Persons are entitled to participate in the inquest. They will receive disclosure of relevant materials from the coroner, they may make legal submissions and are permitted to ask questions of witnesses called to give evidence.
    A solicitor to an inquest has a varied role, including:
  • helping a coroner to conduct the investigation;
  • obtaining evidence;
  • overseeing disclosure to Interested Persons;
  • instructing counsel to an inquest; and
  • liaising with witnesses, Interested Persons and their legal representatives.

  • The role of counsel to an inquest may include:
  • presenting evidence;
  • questioning witnesses; and
  • making legal submissions to assist the coroner.