13/11/2025
Inquests and Housing
An inquest is a public hearing and there can be significant publicity that follows. Following a number of high-profile inquests for housing providers reported in the press involving tenants and former tenants, this article explores the circumstances in which housing providers can become involved with an inquest and how to manage the process, including some practical tips.
Health and care providers are very familiar with the inquest process, as by reason of the services being provided, they are often involved with the inquest process and they are also used to carrying out their own internal investigations following the death of someone receiving care and support. For some housing providers, thankfully, there are less inquests that require their input, but this does mean that when an inquest does take place the necessary experience and systems may not be in place to deal with this. In addition, the inquisitorial process is very different to other court processes that providers may be more familiar with.
An inquest is an investigation into a death which can appear to be due to unnatural, violent or unknown causes. The inquest process is designed to answer four questions; who the deceased was, when and where they came by their death and how (and in what means) they came by their death. Housing providers could be called to become involved in an inquest due to suggestions that poor housing contributed to the death or other health and safety issues, where there were safeguarding concerns regarding a vulnerable tenant, for example self neglect, hoarding, cuckooing or domestic abuse. There may also be deaths of other members of the public or staff when carrying out their duties, which then form the basis of an inquest.
At the conclusion of the inquest, the Coroner (or jury in some circumstances) will make findings of fact based on the evidence heard at the inquest and provide a conclusion. Whilst the Coroner cannot determine issues of liability as a Judge would in a civil claim, there is the potential for the conclusion to include criticism for a housing provider.
Coroners also have a duty to consider future deaths throughout the inquest and if the Coroner has concerns, they are under a duty to issue a Prevention of Future Deaths (“PFD”) Report (like in the tragic death of 2 year old Awaab Ishak who died due to a severe respiratory condition due to prolonged exposure to mould in his social housing home). Within the report, the Coroner will detail any risks that they consider need to be addressed and the recipient will be given 56 days within which they must report to the Coroner. PFD reports are published online and can receive a significant amount of press attention.
It is important when a death occurs that organisations consider what lessons can be learnt to mitigate the risk of a death occurring in the future with similar circumstances. This could include consideration of policies that could be put in place, conducting audits and providing training to staff.
The level of involvement in the inquest process will depend on the facts of each case. The Coroner can request documents such as a provider’s policies and procedures, housing records and witness statements from staff. It is possible that the witness statements will be read, but sometimes witnesses will be called to give evidence at the inquest itself, which can of course be a stressful and sometimes distressing experience.
Interested Persons status and involvement with the inquest process
When individuals or organisations have a proper interest in proceedings, they are given some rights to participate in the investigation and inquest they are known as Interested Persons (“IPs”). The Coroner will determine which individuals and organisations are granted IP status on the facts of each case.
There are several categories of those entitled to IP status which are set out in s.47(2) Coroners and Justice Act 2009. Under s.47(2)(f) anyone who may by their act or omission have caused or contributed to the death of the deceased, or whose employee or agent may have done so will be entitled to IP status.
The key rights that come with IP status include:
- To be given advance notification of hearings and be informed of adjournments
- To be provided with witness statements and other documents relevant to the inquest.
- To examine witnesses; and
- To make submissions to the Coroner regarding the inquest procedure and conclusions.
The decision for an individual or organisation to apply for IP status will be specific on the facts of each case.
When to seek advice
The first contact from a Coroner may be in relation to seeking a statement or evidence. There may be notice of a pre-inquest review hearing, which an organisation is invited to attend. At a pre-inquest review hearing some important decisions will be made such as the scope of the inquest and the witnesses to be called. It is not uncommon for communication to be initially directly with a contact within the organisation such as a manager. It is important that an organisation has a clear policy in place for staff to understand who to escalate communications from the Coroner to with consideration of whether legal advice is required at an early stage and whether insurers should be contacted.
Seeking early legal advice will ensure that witnesses are supported and any potential conflicts of interest between the organisation and witnesses can be identified at an early stage.
Processes running in parallel and internal investigations
Depending on the circumstances of a death, there are various regulatory processes which often run in parallel to inquests. These include police investigations and criminal proceedings and Health and Safety Executive (“HSE”) investigations. Civil claims can be pursued either before an inquest or following a conclusion. Dependant on the facts of the case, it is possible that a Safeguarding Adults/Children’s Review (“SAR”) or Domestic Homicide Review can be undertaken. Housing providers are often key partners in these reviews.
Registered Providers of social housing should consider communication with the Regulator of Social Housing.
If the death relates to a resident who was in a CQC registered setting, then there can be further regulatory implications, investigations and potentially prosecutions.
It may be that a provider wishes to carry out its own internal investigation into the circumstances that gave rise to the death. It is important to consider the parallel processes that are taking place when thinking about such an investigation and it is also sensible to take advice.
Documents and record keeping
It is extremely important that employees of housing providers are reminded to ensure that documentation is kept on file and records are kept up to date and stored appropriately. The Coroner is entitled to request copies of records that they deem to be material to the facts of the inquest and may include: repair records, records of communication with tenants, minutes of internal meetings, housing surveys and inspection reports, tenancy contracts and any other document that may be relevant to the inquest.
Notwithstanding the importance of ensuring that records are kept up to date for internal compliance, it is also helpful if employees are subsequently asked for statements by the Coroner to be able to refer to the records to assist their memories of events. In some circumstances the request from the Coroner for a statement may come a few years after the event.
If a housing provider becomes involved with an inquest, it is very likely that the Coroner will request copies of policies in place at the time of the death which are relevant to the circumstances.
Support for witnesses
It is extremely important to ensure that witnesses are sufficiently supported through the inquest process. If witnesses are called to give evidence at an inquest from your organisation, it is highly likely, that this will be the first time that they have been asked to give evidence at court and they may find the process stressful and intimidating.
We can support witnesses through the process to ensure that they are properly prepared and to enable them to deliver their evidence confidently and competently.
Key takeaways
We can assist with:
- Screening cases to see if representation is necessary – reviewing papers, statements etc.
- Supporting witnesses through the inquest process to ensure that they are properly prepared and to enable them to deliver their evidence confidently and competently.
- Advising on all associated regulatory processes and health and safety law and multi-agency investigations.
- Advice and support with policy and process review and formulation.
- Advising organisations where a potential conflict of interest has arisen with an employee and any associated employment advice.
