Role of Coroner


An inquest is a fact-finding examination of a violent or unnatural death, sudden death of unknown cause, or death which has occurred in prison. It is not a method of apportioning guilt, as would be the case with a criminal trial. The inquest verdict cannot be framed in such a way as to appear to determine matters of criminal liability on the part of a named person or civil liability.

In an inquest, there are no parties, no indictment, no prosecution, no defence, and no trial; there is simply an attempt to establish the facts.

The inquest is conducted by a Coroner, and she or he hears evidence relating to the body and the circumstances of the death of a deceased person.

The inquest is a form of public investigation to determine the truth. It is not a trial so there are no formal parties.  It is an inquisitorial process, a process of investigation unlike a trial where the prosecutor accuses and the accused defends. Section 16 of the Coroners Act 1988 states that a Coroner shall adjourn an inquest until the conclusion of any relevant criminal proceedings.

It is a fact-finding process conducted by a Coroner, with or without a jury, to establish reliable answers to four important but limited factual questions. Section 8(3) of the 1988 Act sets out the circumstances in which an inquest must be held with a jury.

The first factual question addressed by an inquest relates to the identity of the deceased, the second to the place of the death, the third to the time of death. In most cases these questions are not hard to answer but in a minority of cases the answers may be problematical. The fourth issue, to which evidence and questioning are usually most closely directed, relates to how the deceased came by their death.


A Coroner is an independent judicial office holder acting on behalf of the Crown to investigate the cause and circumstances of violent or unnatural deaths, or sudden deaths of an unknown cause. Most Coroners are lawyers rather than doctors, although members of either profession can be appointed.

Coroners are appointed by and paid via the local authority for their district, but they are not local authority employees and are independent of both local and central government.

Prior to the appropriate provisions of the Coroners and Justice Act 2009 coming into force, Coroners appointed Deputy Coroners, and in larger districts, Assistant Deputy Coroners to assist them with their workload, which is substantial. Where senior members of the judiciary were appointed by the Coroner for a particular district to deal with particularly complex inquests, they were appointed as the Coroner's Deputy or Assistant Deputy with jurisdiction over the particular inquest(s) in question. By virtue of the 2009 Act, Assistant Deputy Coroners automatically became Assistant Coroners. Assistant Coroners are able to perform all the functions of Coroners under paragraph 8 of Schedule 3 of the 2009 Act.

Previous appointments of serving and retired judges as Assistant Deputy Coroners include:  Lady Justice Hallett to conduct the inquest into the deaths of those killed in the London bombings on 7 July 2005;  Lord Justice Scott Baker to conduct the inquests into the deaths of Diana, Princess of Wales and  Dodi Al Fayed; Sir Michael Wright to conduct the inquest into the death of Jean Charles de Menezes; HHJ Peter Thornton QC to conduct the inquest into the death of Ian Tomlinson in the City of London; and more recently Sir Robert Owen who is conducting the inquest into the death of Alexander Litvinenko. Like these appointees, HHJ Keith Cutler has the same powers as a Coroner when conducting an inquest.

His Honour Judge Keith Cutler CBE

His Honour Judge Keith Cutler CBE

His Honour Judge Keith Cutler CBE was appointed by the Coroner for the North London District of Greater London to be an Assistant Deputy Coroner for the purposes of conducting the inquest into the death of Mark Duggan on 4 August 2011. On 25 July 2013, by virtue of paragraph 3(3) of Schedule 22 of the Coroners and Justice Act 2009 Assistant Deputy Coroners automatically became Assistant Coroners.

His Honour Judge Keith Cutler CBE is a Senior Circuit Judge and has been Resident Judge of Winchester and Salisbury since 2009. He is the Recorder of Winchester. He was called to the Bar (Lincoln’s Inn) 1972.