What is a Coroner?
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.
What do Coroners do?
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.
Which deaths are referred to the Coroner?
Approximately half of all deaths in England and Wales are referred to HM Coroner.
Possible reasons for referral to the coroner are as follows (derived mainly from paragraph 5 of the Notes for Doctors with the MCCD):
- the cause of death is unknown
- the deceased was not seen by the certifying doctor either after death or within 14 days before death
- the death was violent or suspicious
- the death was unnatural
- the death may be due to an accident (whenever it occurred)
- the death may be due to self-neglect or neglect by others
- the death may be due to an industrial disease or related to the deceased’s employment
- the death may be due to an abortion
- the death occurred during an operation or before recovery from the effects of an anaesthetic
- the death may be a suicide
- the death occurred during or shortly after detention in police or prison custody
- the death occurred while the deceased was subject to compulsory detention under the Mental Health Act
- for any other concerning feature
A hospital death should always be reported by a senior doctor.
The coroner (by a coroner’s officer) may wish to contact you about the written referral.
Once a death is referred to the coroner, the reporting doctor may not issue an MCCD to a family until agreed by or on behalf of the coroner.
Where the medical cause of death is agreed by the coroner, the doctor signing the MCCD must indicate that the coroner has been informed and must record
the exact words as agreed with the coroner (with no abbreviations).
The above list is not exhaustive.
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.
Reports are made mainly by doctors and the Police. Upon receipt of a death report the Coroner will review the information and decide what should be done. Please see below for the various possibilities.
What will the Coroner do once a death has been referred?
When a death is reported to the Coroner’s Office the Coroner will usually consider the information on the same or the next working day. The following sections set out some of the possible courses of action the Coroner will take.
Families may be concerned about the process and especially whether it will delay the funeral. Every effort is made to complete the Coroner’s inquiries as quickly as possible.
In some cases the Coroner will review the available reports and be satisfied that the person died of natural causes. There is therefore no need to inquire any further and permission will be given to the GP or hospital doctor to issue the Medical Certificate of Cause of Death (MCCD). 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.
Coroners generally complete enquiries very quickly and usually within the same or 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.
Will there be a Post-Mortem examination?
A post-mortem examination will be necessary if;
- The cause of death is not known. Even if the cause is likely to be natural it may be necessary to find out which disease or condition was involved.
- The cause of death may be unnatural.
- The deceased died in some circumstances of state detention.
Please be assured that a Coroner never requests a post-mortem examination without careful consideration. Where it seems likely that death was due to natural causes, every effort is made to trace a doctor who may be able to certify the cause of death.
Where will the post-mortem examination take place? Who will perform it?
In almost all cases the post-mortem examination will take place at a local Hospital (some exceptions apply, if your relative’s body needs to be moved between hospitals).
The post-mortem examination will usually take place and the body released for funeral within a week of the death but the Coroners office and your funeral director will keep you informed.
Post-mortem examinations are carried out by Consultant Pathologists (or trainees under the supervision of a Consultant Pathologist). When conducting post-mortem examinations they do so on behalf of and at the direction of HM Coroner and not a Hospital Trust.
Relatives at their expense are entitled in law to send a representative to observe the post-mortem examination. The representative must be a qualified medical doctor.
Specialist post-mortem examinations
If there are suspicious circumstances and the police are investigating the death then the Coroner will request a forensic post-mortem examination. This is a more detailed examination performed by a specially trained Pathologist.
Occasionally the Coroner may ask a pathologist who specialises in a particular organ, such as the brain or heart, to carry out the post-mortem examination. The body may be transferred to another local hospital for this or perhaps only the organ in question is sent there
Communication with you?
The next of kin or alternative agreed point of contact for the family will be contacted by telephone usually by the Coroner’s Officer who will discuss post-mortem examination arrangements. The Officer will call again as soon as possible after the examination to explain the results and discuss what happens next.
On occasions it is sometimes not possible to trace or contact relatives, after making reasonable efforts, so the post-mortem examination may have to proceed without notifying them.
Can I still view my relative's body/have an open casket?
The mortuary technicians are very careful and make every effort to ensure that the post-mortem examination does not affect your relative's appearance. When the body is dressed and lying in the Chapel of Rest, there are usually no visual signs that the post-mortem examination took place. 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 an invasive post-mortem examination being carried out on their relative. Coroners understand and respect the basis of these objections however they must also uphold the law and apply it fairly to everyone. The Coroner has the authority to make the final decision and if necessary can request a post-mortem examination even if the family does not agree. This is clearly a very difficult situation and Coroners will do all they can to support you and minimise the delay to your funeral arrangements.
Can I appeal against the Coroner’s decision to order a post-mortem examination?
Families can, if they wish, make representations to the Coroner in writing. This can be done by email or by letter. If you let the Coroner know you plan to do this, they will not start the post-mortem examination until the Coroner has looked at the further information you have given and you have been spoken to about the reasons for the decision.
Is it possible to do an MRI or CT scan as an alternative?
In some cases, it is possible to determine the cause of death by post-mortem imaging. If you want to explore the possibility of using a scanner, let the Coroner know, and the Coroner will decide whether it is an appropriate case.
Not every Coroner Area can offer this without charge, nearby or quickly but the Coroners Officer will be able to explain the available options to you.
If imaging does not reveal the cause of death, a post-mortem examination will still be necessary.
What happens when the results of the Post-Mortem examination come back?
When the post-mortem examination is completed, the Pathologist will report their findings to the Coroner and then one of three things will happen;
If the post-mortem examination confirmed that the deceased died of natural causes the Coroner’s involvement will cease and paperwork will be issued to allow the death to be registered.
If the cause of death could not be immediately identified and the pathologist is to undertake further tests the Coroner will commence an Investigation which may or may not include an Inquest.
If the post-mortem examination revealed an unnatural cause of death an Inquest will be opened and a date for pre-Inquest review and/or final hearing will be set in consultation with you.
The timescales for the results of Post-Mortem examination results varies between Areas but the Coroners Officer should be able to give you some details.
As soon as the Pathologist sends through the result of the post-mortem examination the Coroners Officer will make contact with the agreed point of contact for the family to explain the findings.
Post-mortem examination 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 - the underlying cause of 1a
1c - the underlying cause of 1b
2 - any disease or condition that did not cause death but contributed in some way
While we can explain the causes of death that the pathologist found, we do not have your relative's full medical history. If you have questions about their individual case or the treatment they received, you may want to speak to a doctor that treated them at hospital, or to their GP.
Obtaining a copy of the post-mortem examination report
If the cause of death is ascertained at the time of the post-mortem examination the Pathologist will tell the Coroner about the findings immediately. The timescales for the full written report varies between Areas
Coroner are usually content to share a copy of the pathologist’s post-mortem examination report with the next of kin or other “interested persons” but bear in mind that the report contains detailed and explicit medical information and many people find this distressing to read.
The Coroner’s Officer will provide an overview of the content of the Pathologist’s report but they are not usually medically trained and so detailed explanations of post-mortem examination findings may be better addressed by your GP.
Inquest without Post-mortem examination:
In a number of cases, the Coroner decides that an Inquest to look into the circumstances of the death is necessary but a post-mortem examination is not. For example the death of an individual who died from an Industrial Disease diagnosed in life. These are fact dependent and if appropriate the Coroner’s Officer will talk through this process with you.
What about organ donation?
Coroners endeavour to support the valuable work of the NHS Transplant Service and will facilitate donation wherever possible. However, Coroners must ensure that this does not compromise any investigations.
If a death requires referral to the Coroner, organ donation can only take place if the Coroner does not object to it. If a post-mortem examination is not necessary there will usually be no difficulty with donation. If a post-mortem examination is required 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.
What happens if samples are taken at Post-mortem Examination?
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.
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.
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.
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.
A cause of death is given. What next?
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.
There is no Cause of Death. What next?
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).
What if I have concerns about the death?
If you have concerns about matters causing or contributing to your relative’s death please let us know as soon as possible.
Sometimes we may advise you that your issues would be better addressed by another organisation such as the hospital’s Patient and Advice Liaison Service or the Care Quality Commission. This does not mean that your concerns aren’t valid; only that they are outside the scope of the Coroner's inquiries.
If you want to tell us about concerns, please do this in writing by post or email and ideally within 14 days of the commencement of the Coroner’s Investigation. If an Inquest has been opened, you can also send a list of questions that you would like to ask the witnesses at the hearing. Please write as clearly and briefly as you can.
If the death has not been reported to the Coroner at all but you have concerns about the circumstances of the death please let us know and the Coroner will consider whether the matter requires further investigation.
What happens at an Inquest?
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.
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.
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.
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;
Road traffic collision
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’.
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.
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.