This guide is intended for bereaved people and others who may be affected by a coroner investigation or are attending a coroner’s inquest. The guide provides bereaved people with an explanation of the coroner investigation and inquest process as well as links to other organisations that may also provide help and advice. Whilst the guide is focused on bereaved people, it will also be useful for others, including other interested persons and witnesses as well as members of the public who want to understand coroner processes. The guide includes a protocol of key principles which applies when a government department has interested person status in an inquest. The protocol aims to ensure that the department recognises the need for bereaved people to be involved throughout the inquest process. The guide is not intended as a statement of the law and does not cover every situation that might arise.

Maria Ferreira, a woman with Down’s syndrome, died in an intensive care unit after she dislodged a tube with her mittened hand. An inquest was to be held but whether a jury was required depended upon whether she died in “state detention” under sections 7 and 48 of the Coroners and Justice Act 2009. A key issue, therefore, was whether “state detention” equated to “deprivation of liberty” under Article 5(1) ECHR and the relevance of the Supreme Court’s decision in Cheshire West. The Court of Appeal concluded Ms Ferreira was not in state detention.