FAQ’s

A Coroner is an independent judicial office holder, appointed by the local authority.  Coroners are usually lawyers who work within a framework of law passed by Parliament.  The Chief Coroner heads the Coroner service and gives guidance on standards and practice. 

Coroners investigate deaths if they have reason to suspect that:

• The death was violent or unnatural; or
• The cause of death is unknown; or
• The deceased died while in state detention. 

When a death is reported to a Coroner they:

Make preliminary inquiries to decide if an investigation is required;

If so investigate to establish the identity of the person who has died; how, when, and where they died; and any information required to register the death; and

May use information discovered during the investigation to assist in the prevention of other deaths.
 

The Coroner may decide to hold an Inquest as part of the investigation. 

Other sections on this website explain the different possibilities more fully. In all cases, the Coroner aims to accommodate families' funeral plans while making sure that the investigations are effective and complete.

Approximately one third of all deaths in England and Wales are referred to HM Coroner. 

The Notification of Deaths Regulations (2019) http://www.legislation.gov.uk/uksi/2019/1112/made sets out the deaths which must be referred to the Coroner, summarised below;

a)  there is a suspicion that the person’s death was due to;

• Poisoning, including by an otherwise benign substance;
• exposure to or contact with a toxic substance;
• the use of a medicinal product, controlled drug or psychoactive substance;
• violence;
• trauma or injury;
• self-harm;
• neglect, including self-neglect;
• the person undergoing a treatment or procedure of a medical or similar nature;
• an injury or disease attributable to any employment held by the person during their lifetime.

b)  it is suspected that the person’s death was unnatural but does not fall within any of the circumstances listed above.

c)  the cause of death is unknown

d)  the person died while in custody or in state detention

e)  there is no attending medical practitioner to sign a death certificate (MCCD)

f)  the attending medical practitioner is not available within a reasonable time to sign a MCCD

g)  the identity of the deceased cannot be ascertained.

Referrals are mainly made by doctors, medical examiners and the Police and when a coroner receives a death referral, the coroner will decide whether there is a duty to investigate and may undertake preliminary enquiries before making that decision. The coroner will usually consider the information on the same or the next working day but sometimes it can take longer if, for example further information is required or a doctor has to be located who can issue the MCCD. The process thereafter will depend on the circumstances.

Where the death did not occur in custody or state detention and the coroner decides without commencing an investigation that it was natural, the coroner will complete either form CN1A or CN1B and the case will be determined on the medical side of the death certification system by an attending practitioner and/or medical examiner. Relatives can then register the death at the Register Office just as they would have had the MCCD been issued without referral to the coroner. Once this has been done the funeral can take place.

When a coroner has decided that the duty to investigate is engaged and commences an investigation, responsibility for determining the cause of death for registration purposes sits with the coroner.

A coroner may discontinue the investigation if they determine that the death is natural and did not occur in custody or state detention. The coroner will then complete form CN2 and send it to the registrar. The Register office will then contact relatives to complete the registration of the death. The coroner will also send a Notice of Discontinuance to the family and issue either a Form Cremation 6 or an Order for Burial, to enable the funeral to take place.

If there is any doubt the Coroner’s Office should be contacted for further advice.  If you are unsure why your relative’s death has been reported please call us and a Coroner’s Officer will discuss it with you.

Some of the possible courses of action the coroner will take are set out in the sections that follow. 

Post-mortem (PM) examinations

Detailed guidance has been issued by the Chief Coroner which can be found at guidance sheet 32 (first and second PMs) and sheet 1 (PM imaging.)

Will there be a PM in every case?

No. A PM is likely to be necessary if;

• A cause of death unknown.  Even if a death is likely to be natural it may be necessary to find out which disease or condition caused it. 
• A death is from an unnatural cause.
• The deceased died in custody or otherwise in state detention. 

What about the Medical Examiner (ME?)

Deaths that are obviously unnatural will likely be referred to a coroner direct who will consider the necessity for a PM.

Since September 2024, however, all deaths are now the subject of independent scrutiny and those not automatically referred to a coroner will be scrutinised by an ME. Where an ME agrees with a reporting doctor (Qualified Attending Practitioner – QAP) that a death was from natural causes and a particular cause can be identified, the QAP will produce a Medical Certificate of the Cause of Death (MCCD) allowing the death to be registered without a PM or involvement of the coroner. If a death is from a natural cause but there is no available QAP (perhaps where a deceased moved shortly before death and without being seen by a new doctor) an ME may be able to produce an MCCD and avoid a PM.

Are there different types of PM?

Yes. Among the different options are:

• A forensic PM. This will be conducted by a Home Office registered forensic pathologist and tends to be limited to those cases where there has been a death in suspicious or unexplained circumstances and/or where contemplation is being given to criminal proceedings arising out of the circumstances of a death.
• A hospital PM. This will be conducted by a hospital pathologist. This will include the vast majority of coroner PMs.
• An external only PM. In some areas of the country, a pathologist may feel able to provide a cause of death without an invasive procedure, for example, where someone is believed to have died from hanging and a pathologist is able to identify a ligature mark around the neck (toxicology may still be required.)
• A minimally invasive PM – please see Chief Coroner Guidance Sheet 1.

 

 

Can I be represented at the PM?

Relatives are entitled in law to send a representative to observe a PM at their own expense.  The representative must be a qualified medical doctor.   

Specialist post-mortem examinations

Occasionally a Coroner may ask a pathologist who specialises in a particular organ, such as the brain or heart, to carry out a specialist examination.  The whole body or just a particular organ may be transferred to another local hospital for this purpose

Communication with you.

The next of kin or agreed single point of contact for the family will be contacted by telephone, usually by a Coroner’s Officer, who will discuss the arrangements for the PM.  The Officer will call again as soon as possible after the examination to explain the results and discuss what happens next. 

Can I still view my relative's body/have an open casket?

Mortuary technicians are very careful and make every effort to ensure that a PM does not affect your relative's appearance.  When a body is dressed and lying in a Chapel of Rest, there are usually no visual signs that a PM has been performed. Your funeral director will be able to give you advice on your personal situation.

Objections to post-mortem examinations and religious considerations

Some families object to their relative having an invasive PM. Coroners understand and respect these objections, however, in prescribed circumstances, they have a legal duty to ascertain how a person has died. This can make for very difficult discussions.

Coroners will routinely apply themselves to the order in which PMs take place on a given day to try and expedite the release of a body for burial or other respectful disposal where, for example, there are religious considerations. Upon request, they can also look at alternative forms of investigation, for example, minimally invasive examinations (see Chief Coroner Guidance Sheet 1.) The availability of suitable facilities varies across the country. It must also be noted that, on occasions, a minimally invasive procedure will not identify a cause of death which may then necessitate an invasive procedure.

A coroner must apply the law. For that reason, the law provides a coroner with the authority to make a final decision and, if necessary, to order a PM even where a family objects.

 

Can I appeal against a Coroner’s decision to order a PM?

Families can, if they wish, make representations to a coroner in writing.  This can be done by email or by letter.  If you let a coroner know you plan to do this, they will not start a PM until they have looked at the further information you have given and you have had the reasons for a decision explained to you. 

What happens when the results of a PM come back?

When a PM is completed, a pathologist will report their findings to a coroner and one of three things will happen:

1. If a PM confirmed that a deceased died of natural causes a coroner’s involvement will cease and paperwork will be issued to allow the death to be registered; 
2. If a cause of death could not be identified and a pathologist has to undertake further tests (for example, histology or toxicology) a coroner will commence an investigation which may or may not require an inquest; 
3. If a PM revealed an unnatural cause of death an inquest will be opened and a date set for a pre-inquest review and/or a final inquest hearing. 

How is a cause of death formulated?

PM results are set out in a particular format.  The same format is used on the final death certificate from the Register Office.

1a    -      the disease or condition immediately causing death

1b    -      any underlying cause of 1a

1c    -      any underlying cause of 1b

1d    -      any underlying cause of 1c

2      -      any disease or condition that was not the immediate cause of death but made a substantial contribution to it.

While a coroner (or their Officer) will explain the cause of death that the pathologist has found, they will not have your relative's full medical history available to them and are not medically qualified.  If you have questions about an individual case or the treatment a relative received, you may want to speak to a doctor that treated them at hospital, or to a GP.

Obtaining a copy of the post-mortem examination report

If a cause of death is ascertained at the time of a PM, a pathologist will inform the coroner of the findings immediately. A full written report, however, will not be available for several weeks thereafter. The timescales for the production of a full written report vary between coroner area. 

A coroner will usually share a copy of a pathologist’s PM report with the next of kin or other “interested person” upon request. The report will contain detailed medical information and some families will find its contents distressing to read. 

Inquest without a PM

In some cases, a coroner may decide that while an inquest to determine the circumstances of a death will be necessary, a PM will not be required, for example, where someone has died an unnatural death from an industrial disease due to asbestos exposure that has been diagnosed in life. These decisions are fact-specific.

 

 

A coroner will only be involved in a potential donation where there is a duty to notify them of the donor’s death. In cases where that duty does not arise, a coroner does not need to be notified of the death and has no authority to raise an objection to donation.

Coroners cannot authorise donations; there must be prior consent from the donor (or from someone able to make the decision on the donor’s behalf) before a donation can proceed. In England and Wales, most adults are deemed to have consented to donation unless they have opted out (although families’ views will still be considered).

Coroners are contacted about potential organ donation in the cases where the eventual death may be reported for investigation to consider whether organ or tissue donation may prevent post-mortem investigations bearing upon the cause of death.

Coroners approach all referrals for organ donation positively looking to support the vital work of NHS Blood and transplant. There must be a good reason to object to organ donation. If a post-mortem examination is necessary the coroner will consider which, if any, organs can be donated.  Even if it is not possible to donate internal organs, it is often possible to donate corneas and connective tissue.

There is Chief Coroner Guidance on Organ and Tissue Donation

Pathologists may need to take samples from your relative's body for further testing. For standard post-mortem examinations the testing process can take a while, depending on what type of analysis needs to be done. The Coroners Officer should be able to give you an idea about timescales as they vary between Areas.

Histology

In most cases the process is very much like having a biopsy in life - the samples are approximately the size and thickness of a little fingernail. The Pathologist will look at them under the microscope to confirm what was seen to the naked eye and also look for conditions or diseases that couldn’t be seen to the naked eye.

Organ retention

In a small number of cases it is necessary to retain a whole organ or part of an organ to allow for more detailed examination.

Toxicology

Small quantities of blood, urine or other body fluids may be taken if the Pathologist needs to check for the presence of alcohol, over the counter medications, prescribed medications or drugs of abuse. A full toxicological screen is performed regardless of an individual’s lifestyle or circumstances.

It is not always possible to predict in advance of a post-mortem examination whether histology and/or toxicology samples will need to be retained for testing at a later date but when discussing post-mortem examination arrangements the Coroner’s Officer will speak to you about the possibility of this. The Human Tissue Act 2006 sets down strict regulations for samples and so the Coroner’s Officer will ask you how you would wish any samples to be handled once testing is complete. You have a choice of four options;

A. The hospital should lawfully and sensitively dispose of any samples (which may include cremation)
B. The hospital should retain any samples EITHER as part of the deceased’s clinical record only OR for use in education and training
C. The samples should be reunited with the body prior to the body being released for a funeral (which may delay funeral arrangements)
D. The samples should be returned to the family for a separate funeral at your own expense.

Although the Coroners Office may talk to you about this before the post-mortem examination when you are given you  post-mortem examination results, you will always be informed  if samples have been taken and a record of your decision about retention return to the body or disposal will be made.

Some Areas may complete any forms about this directly or through your funeral director to confirm your wishes after the post-mortem examination has taken place.

If the results of the post-mortem examination show a natural cause of death immediately and there is no other reason to open an Inquest (such as the person having died in custody) the Coroner’s involvement will cease at this point. 

You will be contacted with an explanation about the cause of death and advised to make an appointment to register the death and obtain the final death certificate.  Paperwork will be sent to the Registrars of Deaths from the Coroner’s Officer to inform them of the cause of death. 

Please tell the Coroners Office which funeral director will be looking after the arrangements in order for the Coroner to provide a Mortuary Release form.  This permits the funeral director to collect your relative and take them into their care at their earliest opportunity. 

If there is to be a cremation the Coroner will provide the appropriate paperwork to the funeral director.  If, on the other hand, there is to be a burial you will be provided with the necessary paperwork by the Registrars when you register the death.   ​

The Coroner’s Officer will contact you as soon as the post-mortem examination results are available and explain the cause of death

If the cause of death cannot be immediately established at the time of the post-mortem examination the Coroner will commence an Investigation which may or may not include an Inquest.  Unless there is a reason to investigate the circumstances of the death at the outset the Investigation will be pending the outcome of the pathologist’s written post-mortem examination report. 

Although funeral arrangements may proceed the death cannot be registered until the Investigation has concluded.  In such cases you will usually receive a pack of information from the Coroner’s Office which contains, amongst other things, Coroner’s Certificates of the Fact of Death otherwise known as “Interim Death Certificates” which allow you to deal with your relative’s personal affairs such as closing bank accounts and dealing with other correspondence about the deceased’s estate while the final death certificate is awaited. 

Tell the Coroners Office which funeral director will be looking after the arrangements in order for the Coroner to provide a Mortuary Release form which permits the funeral director to collect your relative and take them into their care at the earliest opportunity.  The Coroner will also provide the paperwork either for cremation or burial to the funeral director. 

It is important that you bring any factual matters relevant to the circumstances of the death to the Coroner’s attention as soon as possible.    

If the death is one of natural causes and there is no other reason to open an Inquest (such as the person having died in custody) the Coroner will discontinue  involvement at this point.  You will receive a “Notice of Discontinuance” in the post confirming the Coroner’s position and advising you to call the Registrars to make an appointment to register the death and obtain the final death certificate.  Paperwork will be sent to the Registrars from the Coroner’s Officer to inform them of the cause of death.

If, however, the cause of death is found to be unnatural or there is a reason to do so there must always be an Inquest hearing (please see section on understanding the Inquest process for further information).   

All concerns are valid, but a distinction needs to be drawn between whether they fall inside or outside of the Coroner’s duty to investigate.

 

Under recent reforms most deaths are independently reviewed by a medical examiner. As part of that process the medical examiner will contact the next of kin and ask if they have any concerns or questions about the cause of death, the care the person received and anything that seemed wrong or unexplained. This is the appropriate point to raise any concerns.

 

If, after review, the medical examiner forms the view that the concerns raised   potentially caused or contributed to death or the cause of death is unknown/unclear then the death will be referred to the Coroner to review. If the concerns fall outside the scope of the Coroner’s inquiry, then concerns can be raised with other organisations such as the Hospital’s Patient and Advice Liasson Service (PALS) or the care quality commission (CQC).

 

The following organisations are tasked with investigating specific deaths and next of kin concerns can also be raised as part of that process:

 

• Prison deaths are investigated by the PPO,
• Police contact deaths are investigated by the IOPC,
• Work related accidents, health and safety failures or occupational diseases are investigated by the HSE,
• Aircraft accidents are investigated by the AAIB.

 

If police are involved in investigating the death the next of kin can also raise concerns with the police.

 

If the matter has been referred to the Coroner a Coroners officer or investigator will be assigned and will contact the next of kin. Any concerns about matters that may have caused or contributed to death or the medical cause of death can be raised with the investigator or officer who will pass the concerns on to the Coroner to review.

 

If a death has not been referred to the Coroner but you have ongoing concerns that potentially caused or contributed to death, then please let the Coroner know as soon as possible and they will consider whether the matter requires further investigation.

 

When considering your concerns it is important to remember that the Coroner conducts a fact-finding investigation, which is very different from litigation. The Coroner investigates and makes factual findings in relation to the medical cause of death along with who, where, when and how the deceased came by their death.

 

If there is to be an Inquest regarding your relative’s death

An Inquest must be held as part of an investigation into certain deaths. For most families, this will be the first time they have dealt with the process.

The reason for an Inquest:

The law says that the Coroner must open an Inquest into a death if there is reasonable cause to suspect that the death was due to anything other than natural causes (a natural disease process running its natural course where nothing else is implicated) or occurred in state detention.

An Inquest is a public, fact finding inquiry to establish who the deceased was, when and where they died and how they came about their death. The Coroner will confirm the particulars required to register the death, the medical cause of death and record a conclusion appropriate to the evidence.

Inquests cannot deal with issues of blame or criminal/civil liability. These can be addressed in other courts if necessary.

Any complaints about care should be addressed to the organisation concerned.

The Inquest may be held with or without a jury depending on the circumstances of the death. Although the Coroner has discretion to sit with a jury he must do so in cases of unnatural deaths of individuals in state detention. There are usually between 7 and 11 jurors summonsed.

Opening an Inquest:

The Coroner must open an Inquest as soon as possible; this will be done by way of a brief public hearing in the Coroner’s Court. The Inquest will be adjourned to a later date for review or for the final hearing to allow time for investigation and information gathering. It is not necessary for you to attend the opening of the Inquest but you are welcome to do so if you wish.

Every effort is made to hear the Inquest within six months of the death. Sometimes the process may take longer if the case is especially complex or if another investigation into the circumstances of the death is running concurrently (such as a police enquiry or an investigation by the Health and Safety Executive for a death at work). Your Coroner’s Officer will keep you updated about progress.

All hearings that are listed can usually be accessed through a Coroners website as they have to be publicly available.

Gathering information/disclosure of evidence:

The Coroner will decide on the scope of an Inquest and determine the nature of enquiries to be undertaken. Once the Coroner is in receipt of all reports and statements, they will be shared with the Interested Persons (see below for information about Interested Persons) and then a decision will be made as to which witnesses are required to attend the Inquest hearing to give evidence in person and whose evidence can be read onto the record in their absence.

Interested Persons:

Section 47(2) of the Coroners and Justice Act 2009 sets out a full list of those considered to be “Interested Persons” but it includes close relatives of the deceased, a person whose actions or omissions may be called into question and “any other person who the Coroner thinks has sufficient interest”. Interested Persons will have the opportunity to ask relevant questions of witnesses either in person or through a representative.

Who will be in Court?

Inquests are held in a publicly open court.  Friends and family of the deceased are welcome to attend.  If you would prefer not to attend because you may find the hearing too distressing that is understandable.  If you do attend however you can choose to leave the Court room during certain points of evidence that may be especially emotive. 

The Coroner will also require other witnesses to attend.  This will be different for each case, but may include doctors, nurses, police officers, carers, eyewitnesses and any other relevant people. 

Because Inquests are public hearings the Coroner cannot exclude the press and media but you do not have to interact with media representatives if you would prefer not to do so.  The Coroenr cannot prevent accounts of the Inquest being published or broadcast.

How long will the Inquest take?

Inquest hearings can last anything from 30 minutes to several days or weeks.  It depends what has happened and what issues need to be explored.  The Coroners Office will endeavour to give you an estimate when the final arrangements are being made. 

Evidence:

The Coroner may require you to give evidence during the Inquest if you have factual information that could assist with the Coroner’s inquiry.    

Please arrive at least 15 minutes before the Inquest is due to start.  If you have received a disclosure file from the Coroner’s Office you may wish to bring this with you together with equipment to make notes.  On your arrival you will be met by either the Coroner’s Officer or a member of the Coroner’s Court Support Service (CCSS).  They will explain what will happen and clear up any questions or concerns.  Families will be asked how they would like their loved one to be called during the Inquest.  You will then either be seated in the waiting area or go straight through into the court room.

There is no dress code but most people choose to dress reasonably smartly mindful of the formality of proceedings.

When the time comes to give your evidence, the Coroner will call you to the witness stand.  You will need to take an oath or affirmation that you will give truthful evidence.  You can do this on the Holy book of your choice or make a non-religious solemn promise.  The Coroner will then guide you through your evidence.  If the Coroner has questions following a witness’s evidence the Cotroner will ask them first and then the Interested Persons will have the opportunity to ask further relevant questions.  

Once you have given your evidence you will usually be free to go but please ask the Coroner for permission before you leave.  You are of course welcome to stay for the remainder of the hearing. 

If you have been asked to attend Court as a witness you may be able to claim travelling expenses and loss of earnings.  Please ask your Coroner’s Officer for a claim form. 

It may be that evidence is to be admitted without the witness being present; this is in accordance with Rule 23 of the Coroner’s (Inquest) Rules 2013.  The Coroner or the Coroner’s Officer will either read the witness statement in full or the relevant parts onto the record. 
 

Conclusions:

The Coroner’s conclusion will be based on all the evidence that is heard.  Interested Persons or their legal representatives will have the opportunity to address the Coroner on the law and conclusions before he makes his final decision (but this is not an opportunity to rehearse the facts again).  The available short form conclusions are;

Accident

Misadventure

Alcohol related

Drug related

Industrial disease

Lawful killing

Unlawful killing

Natural causes

Open

Road traffic collision

Stillbirth

Suicide

As an alternative the Coroner may also give a brief narrative conclusion.  For example in a medical case the Coroner may use such words as ‘died from recognised complications of a necessary surgical procedure’. 

Legal representation:

Bereaved families and other Interested Persons are entitled to be legally represented if they choose.

At most Inquests families and Interested Persons do not have legal representation and are able to ask questions themselves. In more complex cases where lawyers are involved they will ask questions on behalf of the person or organisation they are representing and can address the Coroner on matters of law.

Legal aid funding is not usually available for representation at Inquests so most families have to pay for legal help themselves. The best thing to do is to speak with a firm of solicitors and take advice from them about what is possible. In exceptionally complex cases if the family were unrepresented, the Coroner may support a legal aid application. Your solicitors would approach the Coroner about this for you.

Obtaining a death certificate:

Following the conclusion of an Inquest the Coroner will draw up the necessary paperwork for the Registrars to register the death. The final death certificate will confirm the medical cause of death and will show the Coroner’s conclusion.

Preventing Future Deaths (PFD) Reports from a Coroner:

The Coroner has the legal power and a duty to write a report following an Inquest if it appears there is a risk of other deaths occurring. This is known as a ‘PFD Report under Regulation 28' because the power comes from regulation 28 of the Coroners (Investigations) Regulations 2013.

The report is sent to the people or organisations that are in a position to take action. They then must reply to the Coroner within 56 days to say what action they plan to take.

A copy of the Coroner's report and the replies received will be sent to the family and other Interested Persons and to the Chief Coroner who may publish them on his website

If you Disagree with the Outcome of the Inquest:

If you are an Interested Person and you disagree with the findings of fact or the conclusion of the Inquest, it is possible to apply to the High Court for what is called a 'judicial review'.

Judicial reviews can only be applied for within 3 months of the end of the Inquest. A review may only be given if it can be shown that the Coroner acted unreasonably, unlawfully, irrationally or if there was significant evidence that was not examined or if there was a major irregularity in the way the Inquest was conducted.

If you wish to pursue such a judicial review you should write to the Coroner in the first instance setting out the reasons. If he agrees that there are grounds, he may make the application to the High Court himself. If he feels that the outcome of the Inquest should stand, you may then apply yourself. As this is such a difficult process, you may need to take legal advice.

CD Recording:

Subject to a confidentiality undertaking and payment of the statutory fee of £5 a CD recording of the Inquest hearing may be made available to you upon your written request.

• Covid-19 is a natural disease process
• Covid-19 is an acceptable direct or underlying cause of death for the purposes ​of completing the Medical Certificate of Cause of Death
• Covid-19 is not a reason on its own to refer a death to a coroner under the Coroners and Justice Act 2009