What is the Coroner? They were called in to investigate over 3 in 10 deaths in 2021. The reason is often as simple as you haven’t been seen by your own doctor for more than 2 weeks, or the death is unexpected. Very rarely is there anything to worry about, but their work can help improve medical knowledge. Coroners are independent judicial office holders who must be a lawyer or a doctor, and in some cases is both. They are employed by Local Authorities and cover that council’s area. Each one has a deputy and usually one or more assistant deputies, as a coroner must be available 24 x 7. In 2018, 41% of deaths were referred to them, so it is not at all unusual. If you want to go into their function in way more detail, download the full Guide to the Coroner Service here.
What is the coroner, and what do coroners do?
Coroners inquire into nearly half of all deaths, for example, those that are unexpected, violent or unnatural deaths, sudden deaths of unknown cause, and deaths that have occurred in prison. The reason may be as simple as the attending doctor being on holiday and therefore being unable to explain the death in person. A coroner’s authority to inquire is based on the location of the body, not on where the death occurred. So can see that the coroner is going to be involved in many quite straightforward deaths – so don’t panic!
The coroner, when a death is reported to him will:
- decide if an inquest is required;
- if so, confirm the identity of the deceased and how, when, and where they died;
- try to help prevent further deaths with similar causes, and
- try to reassure the public.
After an inquest, the coroner sends the necessary details to the Registrar of Births and Deaths so that the death can be registered (if it occurred in England and Wales.)
In some cases, a death may be referred to the police. There may be an investigation by a body like the Health and Safety Executive, the Prisons and Probation Ombudsman, the Care Quality Commission or the Independent Police Complaints Commission. The coroner will be given the results of the investigation.
What is a coroner’s officer?
Coroners’ officers work for coroners and liaise with bereaved families, the police, doctors, witnesses, mortuary staff, hospital bereavement staff and funeral directors. They receive reports of deaths and make inquiries on behalf of the coroner.
Are all deaths reported to a coroner?
Under half of all deaths are referred to them. Mostly, the deceased’s own GP, or a hospital doctor who has been treating them during their final illness, can issue a Medical Certificate of the Cause of Death (MCCD.) The death can then be registered by the Registrar of Births and Deaths, who will issue the death certificate. Doctors may discuss marginal cases with the coroner and often the GP will then be able to issue the MCCD and the coroner issue a certificate to the Registrar confirming that an inquest is unnecessary.
Should the coroner decide to inquire into a death, the Registrar of Births and Deaths has to wait for the coroners’ clearance before the death can be registered. The inquiries may take some time, so discuss matters with the coroner’s office before making any funeral arrangements.
When is a death reported to a coroner?
Registrars of Births and Deaths, doctors or the police report deaths to a coroner. Circumstances where it appears that:
- No doctor attended to the deceased during his or her last illness.
- Although a doctor attended during the last illness, the deceased was not seen either within fourteen days before death or after death.
- The cause of death appears to be unknown.
- The death occurred during an operation or before recovery from the effects of an anaesthetic.
- The death occurred at work or was due to industrial disease or poisoning.
- The death was sudden or unexpected.
- The death was unnatural.
- The death was due to violence or neglect.
- The death was in other suspicious circumstances. Or
- The death occurred in prison, police custody or other state detention.
Whilst reports to the coroner usually come from professionals, anyone with good cause may report the death to the coroner. Obviously, this should preferably happen before there has been any interference with the body and before a funeral takes place. The coroner will tell the informant what action the coroner intends to take when reports are made in this way.
What will a coroner do when a death is reported?
The coroner may ask a pathologist to carry out a post-mortem examination (same as an autopsy). Or the coroner may consider that unnecessary as the cause of death is evident and natural and there is a doctor who can sign an MCCD to that effect. The coroner will then confirm to the Registrar of Births and Deaths that further investigation is not required.
What is a post-mortem examination?
It’s a medical examination of a body carried out for the coroner by a pathologist or a specialist doctor to establish the cause of death.
The consent of relatives is not required for a post-mortem, but the coroner is required to inform the deceased’s relatives and GP of when and where the examination will take place, provided they have previously advised the coroner that they would like to be present or represented. They can be represented by a doctor of their choice, at their own expense. Coroners will take account of religious and cultural needs where practicable. Relatives can have a separate autopsy at their own expense when the coroner has released the body should they wish to.
Post-mortem examination report. Post mortems were carried out on 43% of deaths in 2021.
The post-mortem report details the examination of the body and is sent to the coroner by the pathologist. It will also give details of tissues and organs removed from the deceased, and any tests, such as for drugs and blood alcohol level, which have been carried out to assist in unveiling the cause of death. Copies are normally available only to properly interested persons.
The coroner may decide an inquest is not required after a post-mortem if there is no reason to think the person died a violent or unnatural death and did not die in prison. The coroner would then release the body and send a form to the Registrar of Births and Deaths stating the cause of death as reported in the post-mortem report so that the death can then be registered and the funeral authorised. This is provided that the coroner considers that no further inquiries are necessary.
Medical records
Medical records remain confidential but may be shown to the deceased’s personal representatives or anyone who may have a claim arising from the death, subject to some restrictions, under the terms of the Access to Health Records Act 1990 see www.legislation.gov.uk/ukpga/1990/23/contents.
Coroners are entitled to medical information that is relevant and necessary to their inquiries. Medical information about the deceased may be disclosed at the inquest if it is relevant.
Will organs be retained after a coroner’s post-mortem?
Organs and, more commonly, small pieces of tissue may sometimes be removed and preserved if they have any bearing on the cause of death or the identity of the deceased. When the material is no longer needed, it will either be returned to the deceased’s family, if requested or disposed of by burial or cremation. If a pathologist wishes to retain organs and tissue, perhaps for research or training purposes, the consent of the relatives is required. In exceptional cases, e.g. involving murder, the organs may have to be retained for a longer period. See also www.hta.gov.uk.
What happens after the post-mortem if the coroner decides to hold an inquest?
A coroner must hold an inquest if the cause of death remains unknown after the initial post-mortem examination and subsequent tests or if there is cause for the coroner to suspect that the deceased died a violent or unnatural death or died in prison. However, after the post-mortem examination, the coroner will usually give authority for the funeral, even though an inquest may be required but has not been concluded.
In such circumstances, the death cannot be registered. An interim certificate of the fact of death can be issued by the coroner. This certificate should be acceptable to banks and financial institutions unless it is important for them to know the outcome of the inquest (for example, for an insurance settlement). This interim certificate can be used for benefit claims and National Insurance purposes.
When the inquest has been completed, the coroner will advise the Registrar of Births and Deaths so that the death can be registered and a death certificate can be issued.
If criminal charges have been brought against somebody for causing the death, it may be necessary for a second post-mortem examination to take place or for further investigation, and the release of the body and the funeral arrangements may then have to be delayed.
Taking the body abroad or bringing it back to this country.
Always when a body is to be taken out of England or Wales, written notice must be given to the coroner in whose area the body is located. The coroner will then consider whether an inquest or post-mortem examination is needed and will notify the next of kin of his or her decision within four days.
If a body is being brought into England or Wales, the coroner in the area where the body is brought may need to be involved. The coroner may need to determine the cause of death and will be required to hold an inquest if the death was unnatural, violent, or sudden and of unknown cause. The coroner will issue a certificate for cremation in all cases coming from abroad where the body is to be cremated.
When death has occurred outside England and Wales, and the body is returned to England or Wales, the death is not registered by the Registrar of Births and Deaths when the coroner has finished investigating or has concluded the inquest. Further information about what to do when a death occurs abroad can be found on the Foreign and Commonwealth Office’s website at: https://www.gov.uk/government/publications/coping-with-death-abroad.
If cremation takes place abroad and the cremated remains are brought back into England or Wales, they will not have jurisdiction, and therefore, an inquest cannot take place.
They may conduct or order an inquest into the manner or cause of death and investigate or confirm the identity of an unknown person who has been found dead within the coroner’s jurisdiction.In medieval times, they were Crown officials who held financial powers and conducted some judicial investigations in order to counterbalance the power of sheriffs.The word derives from the same source as the word crown, and it is believed to denote an officer of the Crown.
What is the Coroner?
Coroners and Inquests: the coroner is called in when a death is sudden or unexpected or sometimes just because the doctor who had been treating the patient is on holiday. What it doesn’t mean is that the death is being treated as suspicious, so DON’T PANIC. This article is relevant to England and Wales.
If the Coroner is involved:
If organ or tissue donation is intended, immediate advice is needed from the hospital or the coroner’s officer. Then a Tissue Donor Coordinator or a Donor Transplant Coordinator will be able to discuss the options. The coroner must agree before the donation can happen. Sometimes it just won’t be possible for medical reasons, or because the Coroners investigations delay things too long.As next-of-kin, you have the have the right:
1. Who are Coroners?
Coroners are independent judicial officers guided by specific laws and rules. Each coroner has a deputy, and one or the other must be available 24 x 7. Coroners are generally lawyers but may also be doctors.
2. What do Coroners do?
Coroners look into deaths which appear to be violent, unnatural, or of sudden and unknown cause. The coroner will try to discover the medical cause of death. If doubt remains after a post-mortem, an inquest is held.Taking the deceased abroad or bringing them back to England or WalesTo gain permission to take the body abroad, you need to give written notice to the coroner. The coroner will advise you within 4 days if further enquiries are still needed.If you want to bring the deceased back to England or Wales, the coroner asks for advice from your local coroner’s office. The coroner may need to be involved.
3. What is the Coroner’s Officer?
Coroners Officers are often police officers and liaise with families, police, doctors and funeral directors.
4. Are all deaths reported to the Coroner?
No. In mostly, the GP or hospital doctor is able to issue a Medical Certificate and the death can then be registered by the Registrar of Births and Deaths in the normal way.Registrars, doctors or the police must report deaths to the coroner in some circumstances. For example, if the doctor can’t give a Certificate of a Cause of Death, if the death was during an operation, or was due to an industrial disease, or if it was unnatural, due to violence, or in any other suspicious situation.
5. What is a post-mortem?
It’s a medical examination of the deceased for the coroner by a pathologist of the coroner’s choice. The consent of the next-of-kin is not required for a coroner’s post mortem.
6. Post Mortem Report.
The report gives details of the results of the pathologist’s examination of the deceased and of any lab tests. Copies of the post mortem report are usually be available to next-of-kin and to certain other relatives. A fee may be payable.
7. Will Organs be retained after a coroner’s post-mortem?
When the cause of death is known, and further examinations are unnecessary, organs or tissue must be returned to the body. If the funeral has already happened, the wishes of the next of kin are followed and their consent obtained, should pathologists wish to keep or remove anything for research or training.
8. Medical Records.
Medical records are still confidential after death. Coroners necessarily are able to ask for medical information they consider is relevant and necessary.
9. When can the funeral be held?
If the post mortem confirms that the death was from natural causes and an inquest is unnecessary, the coroner will release the deceased and you can then register the death and organise the funeral.If an inquest is required, the coroner can usually give the undertaker a burial order or cremation certificate after the post-mortem. If charges have been brought for causing the death, a second post mortem may be needed and perhaps further investigations. Therefore, the release of the deceased and the funeral may be delayed.
10. Issue of the Death Certificate
Where death was from natural causes, the coroner will tell the registrar and the death can then be formally registered and the Death Certificate issued. However, if an inquest is required, the Coroner may give an Interim Certificate of Fact of Death to help with the administration of the deceased’s estate. When the inquest is over, the coroner notifies the registrar and then a normal death certificate can be issued.
11. What is a Coroners’ inquest?
A coroner’s inquest enquires into who has died and how, when and where the death occurred. It is not a trial; it is not the coroners job to point the finger at anyone, that is for the Police.The coroner’s inquest is formally opened to record that a death has happened and to confirm the identity of the dead person. It is then adjourned until any police and coroners enquiries have been completed. The full inquest can then be resumed.
12. Attendance at an inquest.
When the coroner’s investigations are over, a date for the inquest to continue is made, and the relevant people are notified if their contact details are available to the coroner. Inquests are open to the public and to journalists.
13. Witnesses called to give evidence at an Inquest.
Coroners decide who to call to give evidence. Anyone who thinks they – or another person – can help should offer to give evidence by informing the coroner. Witnesses can be required to attend and give evidence at the inquest.
14. Questioning of witnesses.
Witnesses will be questioned by the coroner and perhaps by “properly interested persons”, or their legal representatives. Questions must be relevant.People with a “proper interest” include:■ parent, child, spouse, (or lawyer representative) of the deceased;■ person who may have a responsibility for the death;■ a beneficiary from an insurance policy relating to the deceased;■ representatives of the insurance company;■ a representative from a relevant trade union (where death was connected to employment or was due to industrial disease);■ certain inspectors or representatives of enforcing authorities or of a government department;■ the police;■ any other people the coroner feels have an interest.
15. Inquests with a jury.
Inquests are held with a jury if death occurs in prison, in custody, at work or if further deaths may occur in similar circumstances. In the coroner decides matters of law and the jury decides the verdict.
16. Coroner’s Inquest verdicts
Inquests do not seek to apportion blame, and the verdict must not identify anyone as having criminal or civil liability.Potential verdicts include:
- natural causes
- accident
- suicide
- unlawful
- lawful killing
- industrial disease
- open verdicts (where there is insufficient evidence for any other verdict).
The coroner may report the death to any appropriate person or authority, such as the police, Highways Authority or the Health and Safety Executive etc if action is needed to prevent more similar deaths.
17. Can you challenge the result of a coroner’s inquest?
You may be able to challenge coroners’ verdicts. However, doing so is complex and needs explanation by an expert lawyer, and it may not be possible. An application for judicial review can be made within three months of the inquest. A new inquest can be requested at any time.
18. Coroners Inquest Records.
Notes of Evidence can be reviewed by properly interested persons. Alternatively, copies may be obtained for a fee. This may be a transcript from a tape recording or the coroner’s own notes. Notes may not be a record of every word said.
19. Criminal proceedings.
If a criminal charge is in the Magistrates’ Court, the inquest should be over before the hearing. If the criminal charge is in the Crown or higher courts, the coroner is told of the result, the Registrar of deaths is advised, and the inquest is generally closed.
20. Civil proceedings.
Civil proceedings (perhaps for compensation) don’t depend on the result of the inquest or criminal proceedings. You should get proper advice about time limits and the procedures.Evidence from an inquest or criminal proceedings may help families understand what has happened and assist with compensation claims. You may wish to take legal advice before the inquest.
21. Is Legal Aid available?
Legal Aid is not normally available for an inquest. Legal advice under the “Green Form” scheme may be available if you are eligible.
22. The Coroner’s Office
Contact details for the local coroner’s office are available from the police.I hope that was reassuring and that you may wish to download our booklet on what to do when someone dies and deal with the paperwork. There is also a free sheet on how to register a death.
Information on Coroners Inquests.
An inquest is usually opened soon after a death to record that the death has occurred, to identify the deceased, and to enable the coroner to issue the authority for the funeral to take place without any unnecessary delay. It will then be adjourned until any other investigations and any enquiries required by the coroner have been completed. This will take an average of just over six months, sometimes longer if the enquiries prove complex. Once enquiries are concluded, the inquest will then be resumed and concluded.The coroner may hold hearings before the inquest itself, where the scope of the inquest and any matters of concern, including arrangements for the hearing, can be considered. The coroner usually invites properly interested persons and/or their legal representatives to the pre-inquest hearing, where they have the opportunity to make representations to the coroner.
What happens if somebody has been charged with causing the death?
Where a person has been sent for trial for causing, allowing or assisting a death, for example, by murder or manslaughter, any inquest is, in most cases, adjourned until the criminal trial is over. On adjourning an inquest, the coroner must send the Registrar of Births and Deaths a certificate stating the particulars that are needed to register the death and for a death certificate to be issued. When the trial is over, the coroner will decide whether to resume the inquest. There may be no need, for example, if all the facts surrounding the death have emerged at the trial. If the inquest is resumed, however, the finding of the inquest as to the cause of death cannot be inconsistent with the outcome of the criminal trial.
Attending an inquest
When a coroner’s investigations into a death are complete, a date for a full inquest will be set. The properly interested persons (essentially the relatives and others closely connected with the deceased) will be informed of the date and time by the coroner’s officer and any witnesses will be asked to attend to provide evidence. The process is held in the public interest and not on behalf of any individual. It is not always necessary for the bereaved relatives to attend the inquest, and some prefer not to, as the details of the death may need to be dealt with in graphic terms. If bereaved relatives do wish to attend the inquest, they can be accompanied by a supporter, for example, a friend.
Is there always a jury at an inquest?
No, most inquests are held without a jury, but there are particular circumstances when a jury is called, including:
- if the death occurred in prison or in police custody, or
- if the death resulted from an accident at work.
In every jury inquest, the coroner decides matters of law and procedure, and the jury decides the facts of the case and reaches a verdict. The jury cannot blame someone for the death. If there is any blame, this can only be established by other legal proceedings in the civil or criminal courts, although the jury can state facts which make it clear that the death was caused by a specific failure of some sort or by neglect.
Who decides which witnesses to call?
The coroner will decide who should be called to give evidence as a witness and the order in which they give evidence. However, anyone who believes they may be of help or believes a particular witness should be called should inform the coroner. The coroner will then decide whether the evidence is relevant to the investigation of the death.
Must a witness attend an inquest?
Yes, if they live in England or Wales. In many cases, the evidence of a witness may be vital in establishing the facts of the death. A witness may either be asked to attend the inquest voluntarily or receive a formal summons to do so, but if they live abroad they cannot be compelled to attend or to give evidence.
Who can ask witnesses questions?
Witnesses will be first questioned by the coroner, and then additional relevant questions may be asked by any properly interested person or their legal representative. Whether a question is relevant to the purpose of the inquest is something the coroner decides. Where relevant, the coroner will warn a witness that he or she is not obliged to answer any question which might incriminate him or herself.
Is Legal Aid available for Inquests?
Legal Aid is not generally available for representation at inquests because an inquest is a fact-finding process. However, exceptional case funding may be available without a means test. Unlike other proceedings for which Legal Aid might be available, there are no parties in inquests, only the properly interested persons, and witnesses are not expected to present legal arguments. The coroner ensures that the process is impartial and thorough, and he or she should assist families in ensuring that their relevant questions are answered.Legal Aid may, however, be available to cover representation at the inquest in very exceptional cases. Generally, applicants must qualify financially, and applications must meet strict criteria for representation to be funded. These criteria are:
- there is a significantly wider public interest (as defined in the Legal Services Commission’s Funding Code) in the applicant being represented at the inquest or
- the applicant is a member of the deceased’s immediate family, and the circumstances of the death appear to be such that funded representation is likely to be necessary to enable the coroner to investigate the case effectively and establish the facts (as required by Article 2 of the European Convention on Human Rights).
Legal advice and assistance – via the Legal Help scheme – is available to those who qualify financially. Further information about solicitors who carry out legal aid work can be found in the Community Legal Service directory on 0845 345 4345 or at www.communitylegaladvice.org.uk.
Inquest conclusions
Possible conclusions as to how the death occurred, as suggested by the Coroners Rules 1984 include:
- natural causes;
- accident or misadventure;
- he or she killed him/herself (i.e. suicide);
- unlawful killing;
- lawful killing;
- industrial disease, or
- open verdict (where there is insufficient evidence for any other verdict).
Alternatively, the coroner can give a narrative verdict which sets out the facts surrounding the death in more detail and explains the reasons for the decision.
It is possible to challenge a coroner’s decision.
What if future deaths may be prevented?
One of the great services coroners do for us is when sometimes an inquest will show that something could be done to prevent other deaths. If so, at the end of the inquest the coroner may announce that he or she will draw this to the attention of any person or organisation that may have the power to take action. Anyone who receives such a report must send the coroner a written response. These reports and the responses to them are copied to all properly interested persons and to the Lord Chancellor. A summary is published twice a year, by the Ministry of Justice.See also information further down on the charity INQUEST, which may be able to offer support to those concerned about Coroners Inquests.
Will the media report the inquest?
All inquests must be held in public in accordance with the principle of open justice, and so members of the public and journalists have the right to, and indeed may attend (although parts of a very small number of inquests may be held in private for national security reasons). Whether journalists attend a particular inquest – and whether they report on it – is a matter for them. If any such report is fair and accurate, it cannot be used to sue for defamation. Those working in newspapers or magazines must abide by the relevant Code of Practice.Suicide notes and personal letters will not usually be read out at the inquest unless the coroner decides it is important to do so. If they are read out, their contents may be reported. Although every attempt is made to avoid any upset to people’s private lives, sometimes, in the interest of justice, it is unavoidable. Photographs taken of the deceased and of the scene of death may also form part of the evidence presented.
What about other proceedings?
Any civil proceedings will normally follow the inquest. When all the facts about the cause of death are known it is possible that civil proceedings may be brought and a claim for damages made. A lawyer’s advice should be sought about the time limits and procedures that apply. Inquest evidence cannot be used directly in other proceedings.
Further information: About INQUEST
“…an organisation that shines a light into the state’s darkest corners, often on behalf of society’s most vulnerable people.” – ‘In praise of…INQUEST’ editorial in The Guardian
INQUEST is the only charity providing expertise on state-related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Our specialist casework includes deaths in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question. This includes work around the Hillsborough football disaster and the Grenfell Tower fire.INQUEST’s policy, parliamentary, campaigning and media work is grounded in the day-to-day experience of working with bereaved people. Employing an integrated model brings together casework support, family participation, identification of thematic trends, statistics and analysis that feeds into the organisation’s work on campaigning, information sharing and policy and parliamentary work. At the heart of this unique model are the experiences and needs of bereaved people. This integrated approach is crucial to families, not only in making sure their voices are heard and holding the state to account for individual deaths but also in changing policy and practice to prevent future deaths.
We are entirely independent of government. Founded in 1981, we campaign alongside families and others to access the truth, hold those responsible to account and effect meaningful change to prevent future deaths.SPECIALIST CASEWORK: We work directly with bereaved people, empowering them through the post-death processes of investigation and inquest to establish the truth about a death in the care of the state.CAMPAIGNING: We use the direct evidence from our casework, alongside statistics and rigorous research, to exert pressure on public bodies and government and drive systemic change.SHARING KNOWLEDGE: We are the only organisation with a comprehensive overview of deaths in custody and detention. We use our expertise and statistics to track patterns and trends and situate deaths in their broader social and political context.SOCIAL JUSTICE: We work to improve the investigation and inquest process for all. We campaign for non-means-tested public funding for families in state-related inquests and stronger post-death investigations. We lobby to ensure that government, state and corporate bodies are held to account and that action is taken in response to systemic failings.Our annual report and accounts are available to download here.
OUR SPECIALIST FOCUS
Our current priority areas of work are:Access to justice for families – equality of arms through developing a system which treats bereaved families with dignity and respect and supports them in navigating the legal process following death and achieving the truth;Visibility with respect to all systems of care and detention – so that failures are exposed, and changes can be made;An end to all institutionalised forms of racism and discrimination – too often a root cause of system failure, individual neglect or violence; these must be recognised and addressed;Accountability for institutional failings and failure to act – effective sanctions and ‘accountable learning’, so that real and relevant action is taken to reduce the number of deaths in future.SEE OUR CAMPAIGNS FOR MORE INFORMATION
OUR VALUES
We work to empower bereaved people, who are often excluded from exercising their legal rights, and to ensure that their collective experience is heard by policymakers, parliamentarians and the wider public.We are committed to challenging racism and discrimination in all areas of our work and have consistently raised concerns about the discrimination and inequality behind many deaths in custody and state care.We work collaboratively and are non-judgemental in relation to the background or actions of an individual who has died.We are dedicated to looking beyond short-term reforms in the current systems and fighting for transformative systemic change.