An inquest is basically an inquiry into a death conducted by a Coroner who is a bit like a judge. He or she can ask questions of the witnesses. Coroners are either doctors or lawyers or both. Most are now lawyers and will soon have to be lawyers.

If you are reading this you have probably lost a loved one to carbon monoxide poisoning. CO-Gas Safety is aware that this is a devastating time and wants you to know that you can always contact us for free, independent, confidential help and advice. We prefer email even if it’s only to let us know that you’d like us to call you but if you’d prefer to call, please ring Mob. 07803 088688. I am living in two places at the moment so although you could try 01483 561633 or 01983 564165 I may not be there and sometimes don’t download messages as I should.

Please read * below.

We are always particularly keen to help those who have lost young children. We are also very keen to help those who have unexplained deaths and whose loved ones may have died from the other toxins in the products of combustion.

Please be aware that Coroners are quite independent and the sort of person the Coroner is can make a huge difference. Some Coroners are incredibly sympathetic and helpful to families. Some are not very approachable at all. Very occasionally families feel that the Coroner is unhelpful or even rude. If you feel this then in our opinion, you really need some independent help and advice so do call us.

Most families want to find out what their loved one died from and why.

Normally it is easy to find out whether or not it was carbon monoxide, (CO) that caused the death. However, it is also important to know that you have a right to a second post mortem or autopsy (i.e. medical examination after death) and that you have a right to appoint your own pathologist to carry out the examination. However, you may be charged for this.

Please be aware that there is no automatic test for carbon monoxide on death. Even if toxicological tests are undertaken these are more often for drink and drugs, not CO and certainly not for the other toxins in the products of combustion.

It is not correct to assume that with regard to a baby or young child that more effort and more tests will be carried out. I was once told by a Coroner’s officer that with a cot death the examination is merely to see if the stepfather killed the child.

If you suspect that the other products of combustion caused the death then this is extremely difficult to prove (see ‘Other toxins’ on the website and do contact the charity for help as you will need it and we will do all we can to help although all we can promise is our support and effort to add to yours).

However, finding out why there carbon monoxide was present is much more difficult.

The vital thing to know is that it is the work you do before the inquest is the most important work for you as a family to undertake.

Some Coroners will send you all the relevant documents. However, many Coroners will not and many will refuse your requests for all the relevant documents, or simply not answer unless you instruct a lawyer to write to the Coroner for you. This is, in our opinion wrong, but it is best that you know how the system works. However, recently new rules have been written to basically encourage Coroners to disclose but disclosure can still be refused on the following grounds or one of them:-

  • the document is subject to legal privilege or other legal prohibition on disclosure
  • the consent of the copyright owner of the document cannot be obtained
  • the coroner consider the request to be unreasonable
  • the document relates to commenced criminal proceedings, or
  • the coroner considers the document to be irrelevant to the inquest proceedings.

The above grounds were copied from

Implementing the coroner reforms in Part 1 of the Coroners and Justice Act 2009

Consultation on rules, regulations, coroner areas and statutory guidance

Consultation Paper CP2/2013

Downloadable from

The problem with carbon monoxide cases is that usually legal privilege is used to refuse disclosure of the investigation undertaken by an expert on behalf of HSE (because HSE will almost invariably have not decided whether to prosecute someone or not before the inques).

* Why is it so important to obtain all the relevant documents before the inquest?

Because if you read these documents carefully, you will no doubt come up with questions that you would like to ask of the witnesses at the inquest or suggest witnesses to be at the inquiry. If you don’t do this in good time, it will be too late. Basically, you need to accept that you only get one inquest and one chance to find out whatever you can about what went wrong. Make the most of it or decide not to bother early on. People with the most regrets are those who made some attempts but they were not determined enough to seek help and after the inquest feel let down and frustrated.

Legal aid for inquests is possible but is not easy to obtain.

Some lawyers will act free for you with regard to the inquest but make sure you know what he or she, will or will not be doing and what he or she would do if paid.

There is an excellent organization called ‘Inquest’ but they basically deal only with deaths in custody although they will offer basic advice. See contact details under ‘Useful addresses.’

There is a new ‘Guide to Coroner Services’ booklet and an accompanying leaflet, ‘Coroner investigations – a short guide’. Published 24.02.14.

The Guide explains to bereaved people, and others who come into contact with a coroner service, what they can expect from the coroner’s investigation.  It sets out the standards of service that they should receive and what they can do if they are not satisfied.  It aims to help to make standards of service more transparent for coroners and bereaved people, as well as assisting the Chief Coroner in discharging his responsibility for overseeing coroner services.

The Guide describes the coroner system in England and Wales under the Coroners and Justice Act 2009, which went live last year.  It replaces and updates the ‘Guide to coroners and inquests and Charter for coroner services’ which applied to the coroner system under the previous coroner legislation (the Coroners Act 1988 and the Coroners Rules 1984).  The Short Guide is a new quick reference leaflet version of the Guide which we have produced following suggestions made by stakeholders in our spring 2013 coroner reform consultation.

The Guide is statutory guidance.  It is issued under Section 42 of the 2009 Act, which allows the Lord Chancellor to issue guidance on how the coroner system is expected to operate in relation to bereaved people, including the way in which they can participate in coroner investigations.

Hard copies of the Guide and Short Guide are being distributed to all coroners’ offices across England and Wales, as well publishing the documents and their Welsh translations on at They will also be available on

November 2014