The Role of the Coroner

A Coroner is an independent judicial office holder appointed by the local authority within the coroner’s area.  In order to be appointed the Coroner must satisfy the judicial eligibility criteria on a five year basis and this means to be a solicitor, barrister or fellow of the Chartered Institute of Legal Executives for a period of five years.

Coroners investigate deaths that have been reported to them if they have reason to suspect that:

• The death was violent or unnatural
• The causes of death are unknown
• The deceased died while in custody or otherwise in state detention

When a death is first reported the Coroner must make some initial decisions:

Firstly, to establish whether an investigation is required.

If an investigation is required to establish the identity of the person who has died, how, when and where they died and any information required to register the death.

The Coroner’s Investigation

The investigation is the process by which the Coroner establishes who has died and how, when and where they died.  As part of this process the Coroner may decide to hold an inquest.

The Coroner’s office has staff employed by the local authority who work under the direction of the Coroner and liaise with bereaved people as well as with the police, doctors, witnesses, mortuary staff, hospital bereavement staff and funeral directors.

There were 529,655 deaths registered in England and Wales in 2015.  Of those, 236,406 were reported to coroners in that period representing approximately 45% of the total.

Registrars of Births and Deaths, doctors or the police must report deaths to a coroner in certain circumstances.  These include where it appears that:

• No doctor saw the deceased during his or her last illness
• Although a doctor attended the deceased during the last illness the doctor is not able or available, for any reason, to certify the death
• The cause of death is unknown
• The death occurred at work or was due to industrial disease or poisoning
• The death was sudden and unexplained
• The death was unnatural
• The death was due to violence or neglect
• The death was in other suspicious circumstances
• The death occurred in prison, police custody or another type of state detention

When a death is reported the coroner will conduct initial enquiries in order to decide whether the duty to investigate arises.   Preliminary enquiries may include:

• Speaking with the deceased’s family
• Speaking with the hospital
• Speaking with the deceased’s GP and if necessary obtaining a copy of the medical records

After carrying out those initial enquiries the coroner may establish that:

• The deceased was seen in his or her last illness by a doctor
• That doctor is able to give a cause of death
• The cause of death is entirely natural
• The family have no concerns which raise suspicion of an unnatural death

The coroner does not need to investigate further and the doctor will be asked to sign a medical certificate of the cause of death.  In these cases the coroner will advise the Registrar of Births and Deaths that, although he or she was made aware of the death, no further investigation is needed.

When the deceased’s GP, or a hospital doctor, certifies the cause of death without referring it to a Coroner, the death can be registered by the Registrar of Births and Deaths, who issues the death certificate.

Where, after making preliminary enquiries the Coroner decides that he or she does not need to investigate the matter further because the death is from natural causes, the doctor concerned may be able to issue the medical certificate of the cause of death and the Coroner will issue a certificate to the registrar stating that it is not necessary for the coroner to investigate the death.

If the Coroner decides to investigate the death, the Registrar of Births and Deaths must wait for the investigation to be completed before the death can be registered.  In most cases the decision to investigate will not hold up funeral arrangements but the Coroner’s office should be contacted before any funeral arrangements are made.  The Coroner may issue a certificate confirming the fact of death.  This certificate may be used to assist in the administration of the estate.

The post-mortem examination is a medical examination of the deceased’s body to try to find out the cause of death.  A Coroner’s post-mortem examination will be conducted by a pathologist on the instructions of the Coroner.

The Coroner decides whether or not a post-mortem examination is needed and also whether any other type of examination is required.  The Coroner is required to give the reason for his or her decision.

If the family have a strong objection to an invasive examination of the body the Coroner may consider other techniques such as CT (computerised tomography) scanning or MRI (magnetic resonance imaging).  It is the Coroner who will decide if a scanning technique is appropriate.  The use of a scanning technique may avoid the need for a full invasive post-mortem examination but if no cause of death is found the Coroner may still proceed with a full post-mortem examination.  The deceased’s family or next of kin will usually be required to pay a fee if scanning is used.

When a post-mortem examination is conducted, the Coroner’s office will inform the family when and where the examination will take place.  The family can be represented by a doctor at the examination although the family would be responsible for that doctor’s fee.

Sometimes the Coroner will request additional scientific information to assist with the establishing the cause of death, for example a toxicological examination to establish whether drink or drugs may have contributed, or a histological examination (looking at tissues under a microscope)

The post-mortem report

The pathologist will give details of the post-mortem examination in a report which is sent to the Coroner.  Sometimes the pathologist’s report may not be available for a number of weeks for example if it is necessary to carry out a specialist examination such as toxicology.

A Coroner may decide to discontinue the investigation if the post mortem examination shows the cause of death and the cause of death is entirely natural.  The Coroner will then release the body so that the funeral can take place.

The Coroner will send a form to the registrar of births and deaths stating the cause of death shown by the post-mortem examination report.

A Coroner may decide that it is necessary to investigate the death further.  However, the Coroner will usually release the body at this stage so that the funeral can take place.

The Coroner must by law continue the investigation and hold an inquest if:

• the cause of death remains unknown after the post-mortem examination and any subsequent tests
• there is reasonable cause for the Coroner to suspect that the deceased died a violent or unnatural death
• the death occurred in custody or state detention

If following the post-mortem examination the cause of death is unknown or the Coroner has reasonable cause to suspect that it is unnatural or if it occurred in state detention or if the Coroner thinks there is good reason to continue the investigation, the Coroner has to hold an inquest to be able to finish the investigation.

An inquest is a hearing held by the Coroner in order to establish the medical cause of death and also the identity of the deceased and how, when and where the death occurred.  In certain circumstances the inquest may be held with a jury, although most inquests are held without a jury.  An inquest is different from other types of court hearings because there are no parties.  The purpose of the inquest is to discover the facts of death.

The final inquest hearing should take place within 6 months or as soon as reasonably practicable after the death has been reported to the Coroner.  Sometimes if the case is complex it may take longer than 6 months.

Opening and adjourning an inquest

Where an inquest is required the Coroner must open the inquest as soon as possible.  The Coroner will then adjourn the inquest until a later date when the Coroner will have all the information required to proceed with the inquest.  It is not necessary for the deceased’s family to attend the opening of the inquest but they are entitled to attend if they wish to do so.

Before inquest is finalised the Coroner may hold a hearing known as a pre-inquest review.  This may be arranged if the circumstances of the death are complex and there are particular issues that the Coroner needs to raise before the inquest is concluded.

Inquest hearings are almost always held in public.

It is usual for a statement to be obtained from a close family member of the deceased.  This person will be invited to attend the inquest to give evidence.  The Coroner will decide which other witnesses are required to attend to give evidence for example a doctor, police officer or eye-witness.  Members of the public and media are normally allowed to attend the inquest.  The Coroner will question a witness first and after that the family member and other “interested persons” may ask the witness relevant questions if the Coroner agrees.  Any questions asked must be relevant to the purpose of the inquest to establish the facts of the death and not to apportion blame.

Inquest conclusions

At the end of the inquest the Coroner comes to a conclusion and this is recorded on the record of inquest.  This includes the legal determination stating formally who died and when, where and how the deceased died.  The Coroner is also required to make “findings” to allow the death to be registered.

When recording the conclusion the Coroner may use a “short form conclusion” which are as follows:

• accident or misadventure
• alcohol/drug related
• industrial disease
• lawful/unlawful killing
• natural causes
• open (used when there is insufficient evidence for any other outcome)
• road traffic collision
• stillbirth
• suicide

Alternatively, the Coroner may make a brief narrative conclusion setting out the facts surrounding the death in more detail and explaining the reasons for the decision.

Sometimes if an inquest shows that something could be done to prevent other deaths the Coroner must write a report drawing this to the attention of an organisation (or person) that may have the power to take action.  This is called “a report to prevent future deaths”.