The work of coroners

This guide is for information purposes only and is not an exhaustive explanation of coroners' law.

The work of the coroner - some questions answered Welsh version ( file size 130 kb)

Who are coroners?

1. Coroners are usually lawyers but in some cases they may be doctors. Coroners are independent judicial officers - this means that no-one else can tell them or direct them as to what they should do but they must follow the laws and regulations which apply. Each coroner has to have a deputy and between them they have to be available at all times. Coroners are helped by their officers, who receive the reports of deaths and make enquiries on behalf of the coroner. Some officers are full-time but in quieter parts of the country they are part-time and often work as policemen or policewomen the rest of the time. The cost of the coroners' service is met by local taxation.

What does the coroner do?

2. A coroner enquires into those deaths reported to him. It is his duty to find out the medical cause of the death, if it is not known, and to enquire about the cause of it if it was due to violence or was otherwise unnatural.

Are all deaths reported to the coroner?

3. No. In most cases the deceased's own doctor, or a hospital doctor who has been treating him or her, is able to give a cause of death.

When is a death reported to the coroner?

4. There are a number of occasions when a death will be reported to the coroner e.g. when no doctor has treated the deceased during his or her last illness or when the death was sudden or unexpected or unnatural.

How are deaths reported?

5. Deaths are usually reported to the coroner by the police or by a doctor called to the death if it is sudden. But a doctor will also report a patient's death if unexpected. In other cases, the local registrar of deaths may make the report.
6. Whenever the death has been reported to the coroner the registrar must wait for the coroner to finish his or her enquiries before the death can be registered. These enquiries may take time, so it is always best to contact the coroner's office before any funeral arrangements are made.

What will the coroner do?

7. The coroner may decide that death was quite natural and that there is a doctor who can sign a form saying so. In this case the coroner will advise the registrar.
8. The coroner may ask a pathologist to examine the body. If so, the examination must be done as soon as possible. The coroner or his staff will, unless it is impracticable or cause undue delay, give notice of the arrangements to, amongst others, the usual doctor of the deceased, and any relative who may have notified the coroner of his or her wish to be medically represented at the examination. If the examination shows the death to have been a natural one, there may be no need for an inquest and the coroner will send a form to the registrar of deaths so that the death can be registered by the relatives and a certificate of burial issued by the registrar. If the person is to be cremated, the certificate may be issued by the coroner.

If the death is not due to a natural cause?

9. The coroner will hold an inquest.

Will the inquest decide who is to blame?

10. No. An inquest is not a trial. It is a limited inquiry into the facts surrounding a death. It is not the job of the coroner to blame anyone for the death, as a trial would do.

What is the purpose of an inquest?

11. The inquest is an inquiry to find out who has died, and how, when and where they died, together with information needed by the registrar of deaths, so that the death can be registered.

What happens is somebody has been charged with causing the death?

12. Where a person has been charged with causing someone's death, e.g. by murder or manslaughter, the inquest is adjourned until the person's trial is over. Before adjourning, the coroner finds out who the deceased was and how he or she died. The coroner then sends a form to the registrar of deaths to allow the death to be registered. When the trial is over, the coroner will not normally resume the inquest.

What about other court proceedings?

13. Any other court proceedings will normally follow the inquest. When all the facts about the cause of death are known, then a person may be brought before another court, or a claim for damages made. The inquest may be of help to the family of the deceased in finding out what happened. The information obtained may also help to avoid similar accidents in future.

Is there always a jury at the inquest?

14. No, most inquests are held without a jury. There are particular reasons when a jury will be called, including: if the death occurred in prison or in police custody or if the death resulted from an incident at work. In every inquest held with a jury, it is the jury, and not the coroner, which makes the final decision (this is called returning the verdict). Jurors are paid expenses and some money towards loss of earnings, if any. They are not expected to view the body, although in some cases they may have to look at unpleasant photographs.

Must a witness attend court?

15. Yes. In many cases the evidence of a witness may be vital in preventing injustice. A witness may either be asked to attend the inquest or receive a formal summons to do so.

Who decides which witnesses to call?

16. The coroner decides who to ask and the order in which they give evidence. Anyone who can help should tell the coroner or his officer who will then see what relevance and help the evidence may be.

Who can ask a witness questions?

17. Anyone who has what is called "a proper interest" (see next paragraph) may question a witness at the inquest. He or she can get a lawyer to ask questions or they can ask questions themselves. Questions must be sensible and relevant. This is something the coroner will decide. There are no speeches.

Who is a "properly interested person"?

18. • a parent, spouse, child and anyone acting for the deceased;
    • anyone who gains from a life insurance policy on the deceased;
    • any insurer having issued such a policy;
    • anyone whose actions the coroner believes may have contributed to the death, accidentally or otherwise;
    • the chief officer of police (who may only ask witnesses questions through a lawyer);
    • any person appointed by a government department to attend the inquest;
    • anyone else who the coroner may decide also has a proper interest. If you ask, the coroner or his officer will advise you whether you have a proper interest.

Is legal aid available?

19. Legal aid is not available to cover representation at the inquest. However, legal advice under the "Green Form" scheme may be obtained by those whose means are within the qualifying limits.

Can future deaths be prevented?

20. Sometimes the inquest will show that something needs to be done to prevent a recurrence. The coroner can draw attention to this publicly and will write to someone in authority about it, for example the council or a government department.

Will the inquest be reported in the papers?

21. All inquests must be held in public and someone from the press is usually present in court. Whether they report the case is a matter for them. At the same time the coroner knows that every death is a personal tragedy and tries to treat each one sympathetically. The inquest tries to get at the truth, and can often help to stop the spread of untrue stories about the death. Suicide notes and personal letters will not be read out unless they have to be, but although every attempt is made to avoid any upset to people's private lives, sometimes, in the interests of justice, it is unavoidable.

Can the funeral be held before the inquest is finished?

22. Yes. If an inquest is to be held, the coroner will normally allow burial or cremation of the body once the examination of the body has finished. However, delay can arise if someone has been charged in connection with the death.

Can a death certificate be given before the inquest is finished?

23. Not normally. However, when the inquest has been adjourned after someone has been charged with causing the death, a certificate can be issued. The coroner may provide an interim certificate of the fact of death so as to assist the personal representatives in looking after the estate.

Is the coroner concerned with organ transplants?

24. If the death has been referred to the coroner, the coroner must be asked to agree to the removal of the organ, since the removal could affect some important evidence. Decisions can usually be made quickly.

Can a report of the inquest be obtained?

25. When the inquest has been completed a person who has a proper interest in the inquiry may apply to see the notes written by the coroner after the inquest, or may have a copy of the notes on payment of a fee. In some cases there may be a tape-recording, or transcript, of the hearing.

Does the coroner have any other functions in relation to a death?

26. The coroner must be notified in every case when a body is to be taken out of England and Wales (whether or not there has been an inquest), and four clear days are allowed for his or her reply, unless written permission is obtained sooner. There is no fee for this. When a body has been brought into England and Wales from another country the coroner may be able to give some help in finding the cause of death and may be required to hold an inquest.

Where can I get more information about the coroner's proceedings?

27. From your local coroner's office. This is usually listed in the telephone directory. Alternatively, your local police or the Citizen's Advice Bureau will be able to tell you where the office is situated.