Coroners & Inquests

What is a Coroner?

Coroners are independent judicial officers in England and Wales who must follow laws that apply to coroners and inquests. Each coroner has a deputy and one of them must be available at all times to deal with matters relating to the inquest and postmortems. Coroners are usually lawyers but may be doctors. They are appointed and paid by the local authority.

What does a Coroner do?

Coroners inquire into death reported to them that appear to be violent, unnatural, or of sudden and unknown cause. The coroner will seek to establish the medical cause of death, if the cause remains in doubt after a postmortem, an inquest will be held.

What is the role of the Coroner’s Officer?

Coroner’s Officers, who may be police officers, work under the direction of coroners and liaise with bereaved families, police, doctors and funeral directors.

Are all deaths reported to the Coroner?

No. In most cases, a GP or hospital doctor can issue a Medical Certificate of the cause of death and the death can be registered by the Registrar of Birth and Deaths, who will issue the Death Certificate in the usual way. However, Registrars, doctors or the police will report death to the coroner in certain circumstances. For example: if a doctor cannot give a proper Certificate of Cause of Death; if the death occurred during an operation; if the death was due to a road crash; or if the death was unnatural or due to violence, or in other suspicious circumstances.

What is a postmortem examination?

A post mortem is a medical examination of a body carried out for the coroner by a pathologist of the coroner’s choice. Coroners will give notice of the need for a post mortem unless this is not practicable or would unduly delay the examination. The consent of the next -of- kin is not required for a coroner’s post mortem, but the next-of-kin can choose to be represented at the examination by a doctor of their choice.
You can ask the coroner for a separate post mortem examination, at your own expense and by a pathologist of your choice. If the coroner has released the body, you will need the consent of the executor of the dead person’s estate.

Postmortem report

This report gives details of the examination of the body. It may also give details of any laboratory tests that have been carried out. Copies of the report will be available to the next-of-kin and certain other relatives. A fee may be payable.

Will organs be retained after a postmortem?

Once the coroner is satisfied that the cause of death is known and no further examinations are needed, organs or tissue must be returned to the body. If a funeral has taken place, the wishes of the next-of-kin must be followed and their consent must be obtained, if pathologists want to retain or remove further organs and tissue for research or training.

When can the funeral be held?

If postmortem reveals that the death was due to natural causes, such as a heart attack and an inquest is not needed, the coroner will release the body and you can register the death. The funeral can then take place. If there is to be an inquest, the coroner can normally issue a burial order or cremation certificate after the postmortem is completed. If charges have been brought or the police are considering bringing charges against somebody for causing the death, it may be necessary to have a second postmortem or further investigations and release of the body and the funeral arrangements will be delayed.

Issue of the Death Certificate

If the death was due to natural causes, the coroner will inform the registrar and the death can be registered and a Death Certificate can be issued. But, if there is to be an inquest, an Interim Certificate of Fact of Death can be issued by the coroner to assist in the administration of the estate. When the inquest is completed, the coroner will notify the registrar. A Death Certificate can then be obtained.

What is a coroner’s inquest?

An inquest is an inquiry into who has died and how, when and where the death occurred. An inquest is not a trial; the coroner must not blame anyone for the death.

An inquest is usually opened primarily to record that a death has occurred and to identify the dead person. It will then be adjourned until any police enquiries and the coroner’s investigations are completed. The full inquest can then be resumed.

Attendance at an inquest

When the coroner’s investigations are complete, a date for the resumed inquest is set and the people entitled to be notified will be told, if their details are known to the coroner. Inquests are open to the public and journalists are usually present.

Witnesses called to give evidence

Coroners decide who should give evidence as a witness. Anyone, who believes they may help, can offer to give evidence by informing the coroner. Anybody, who believes a particular witness should be called, should inform the coroner. Witnesses can be compelled to attend.

Questioning of witnesses

Witnesses will first be questioned by the coroner and there may be further questions by ‘properly interested persons’, or their legal representatives. Questions must be relevant to the purpose of the inquest.

Persons with a ‘proper interest’ include:

  • parent, child, spouse, or legal personal 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 any relevant insurance company;
  • a representative from a relevant trade union (if the death arose in connection with the person’s employment or was due to industrial disease);
  • certain inspectors or representatives of enforcing authorities or persons appointed by a government department;
  • the police;
  • other persons the coroner considers to have a legitimate interest for the purposes of the inquest.

Inquest verdicts

Inquests do not determine blame and the verdict must not identify someone as having criminal or civil liability.

Possible verdicts include;

  • natural causes;
  • accident;
  • suicide;
  • unlawful or unlawful killing;
  • industrial disease;
  • open verdicts (where there is insufficient evidence for any other verdict).

The coroner may also report the death to any appropriate person or authority, if action is needed to prevent more deaths in similar circumstances.

What can you do if you are dissatisfied with the outcome of an inquest?

It is possible to challenge coroner’s decisions or verdicts, but the grounds for doing so are complex and need explanation by a lawyer with expertise in this area of law. An application for judicial review can be made, but this must be done within three months of completion of the inquest. An application for a fresh inquest can be made at any time. All such applications should be made as soon as possible.

Criminal proceedings

If a charge is to be heard in the Magistrates’ Court, the inquest should be completed before the court hearing. If a charge is heard in the Crown or higher courts, the coroner is advised of the outcome, the registrar is informed and the inquest is not normally re-opened.

Is Legal Aid available?

Legal Aid is not normally available to fund legal representation at an inquest. Legal advice under the ‘ÆGreen Form’ scheme may be available for those who are financially eligible.