Our Guide to What Coroners Do

A coroner is a special judge who is responsible for investigating unexplained deaths.

All coroners are members of the judiciary who are appointed directly by the crown and funded by the local authority.

They must have at least five years’ experience as a lawyer and sometimes have medical qualifications, too.

What Does a Coroner Do?

A coroner investigates deaths where the cause is unknown. Their role is to establish basic facts about the deceased and the manner in which they died and to establish whether there is a need for a legal inquest.

As part of their investigations, a coroner has the power to call for a post-mortem, take witness statements, access medical records or launch an inquest in court to help determine facts about the circumstances surrounding the death.

What a Coroner Does Not Do

A coroner is not responsible for deciding whether there has been any wrongdoing. They have no authority to judge who might responsible or liable for the death of the deceased person and only look to find out how someone died.

If, after their investigation, they come to suspect that a person or institution may have played a role in causing the death, they can inform the Crown Prosecution Service or the police. However, any further investigations along this line of inquiry would be carried out by the courts, not by the coroner.

Who Does the Coroner Work For?

The coroner is appointed directly by the Crown and is paid by the Local Authority. A coroner is, therefore, an independent member of the judiciary. The coroner’s staff, who carry out the early stages of the investigation and help gather evidence, are employees of the local authority.

Who Reports Deaths to the Coroner?

Anyone can report a death to a coroner if they believe it may require further investigation. However, in practice, most referrals are made by medical doctors and the police.

When Is a Death Reported to the Coroner?

A case can be reported to the coroner in cases where a death is unexplained, sudden or where a duty of care may have been breached.

This includes cases where:

• The death was sudden or unexplained
• The death may have been the result of an unnatural cause, such as violence, suicide or surgery
• Somebody died in the custody of the state or police
• The circumstances surrounding the death may be deemed suspicious
• The identity of the body or remains are unknown
• A doctor did not tend to the deceased during their final illness

The job of the coroner is then to establish the cause, time and place of death, and confirm the identity of the deceased.

What Does a Coroner Do When a Death Is Reported?

When a death is reported to the coroner, their office makes inquiries to determine whether a full investigation is needed. In some cases, the cause of death may be immediately clear or can be resolved through the initial inquiries made by the coroner’s team.

If this happens, the coroner can issue a ‘certificate of the fact of death’, so the death can be registered and the body released for the funeral.

If the coroner’s office cannot determine the cause of death after their initial investigation, the coroner may request for a post-mortem to be carried out. This is an internal examination of the body, during which a pathologist, who specialised in the effects of disease on body tissue, looks for evidence of how the person died. 

Following the autopsy, the pathologist produces a report. Based on their findings, the coroner may decide to close the investigation or proceed to an inquest.

An inquest may be necessary in cases where legal charges may be pursued in future. This could be because there was a possible crime committed, such as murder, or because a person or organisation is possibly liable for damages, for example, if a person died as a result of negligence while under the care of the state in prison.

The inquest is a fact-finding hearing overseen by the coroner, with no prosecution or defence. Its purpose determines an official cause of death in a court of law.

Why Might a Coroner Order a Post Mortem?

A coroner might order a post-mortem if the cause of death remains unclear after initial investigations, or a doctor cannot certify the death.

Alternatively, a coroner may call for a post-mortem if the circumstances surrounding the death are suspicious or a crime was possibly committed.

What Happens in a Post-Mortem?

The post-mortem is carried out by a pathologist, who is a doctor specialised in the diagnosis of disease from the study of body fluids and tissue. It takes place in a special facility which is licensed by the Human Tissue Authority, in a room which looks a bit like an operating theatre.

Most of the time, a post-mortem is complete within 28 days of a death, however in cases where there has been a possible crime committed, it may take longer.

In any case, where the post-mortem investigation is expected to take longer than 28 days, the coroner must explain why to the family of the deceased.

During the post-mortem, the pathologist makes a single incision down the front of the body through which they can examine the internal organs for evidence of the cause of death. They may also make an incision at the back of the head in order to examine the brain.

The internal organs may be removed during the exam to help the pathologist examine them properly, but are always returned to the body afterwards.

In some cases, the pathologist may need to retain small samples of tissue or fluid for testing in a lab outside of the theatre. If this is needed, the family will always be informed.

At the end of the autopsy, sutures and dressings are applied to the body in the same way as after a normal surgery.

What Does the Coroner Do After a Post-Mortem?

After a post-mortem, the pathologist writes a report of their findings and presents it to the coroner. The coroner then decides whether a cause of death can be determined. If the cause of death was clearly natural, a death certificate can be issued, and the body is released to the family.

However, if there could be legal implications because of how the person died, the coroner will open an inquest.

What Is a Coroner’s Inquest?

A coroner’s inquest is a fact-finding procedure which takes place in court. Unlike criminal cases, there is no defence and prosecution, because the purpose of the court is not to find out who is to blame for the death.

Instead, the coroner calls witnesses, medical experts and other specialists to give evidence, in order to try and determine the exact cause of death.

Once an agreement has been reached, a death certificate can be issued for the deceased.

Even though a coroner cannot pass judgement on whether someone is to blame for the death, they may notify the Crown Prosecution Service or police if their findings suggest there could have been foul play.

Can You Hold a Funeral Before an Inquest?

As soon as a coroner is sure that the body is no longer needed for an investigation, they will release the body. In many cases, this may be before the inquest; however, sometimes the body may need to remain with the coroner until the inquest has finished.

Even if a body is released before the end of an inquest, the death can not be registered until findings are complete. In the meantime, a coroner may issue something called a ‘Coroner’s Certificate of Evidence of Death’ to allow the family to make funeral arrangements.

Can Probate Begin While There Is an Open Coroner’s Investigation?

For probate to begin, the executor of a will usually need to provide a copy of the death certificate in order to close accounts or transfer assets.

However, if there is a coroner’s investigation open, it means the death has not yet been registered. Once a coroner has completed their initial investigation, they can issue a ‘Coroner’s Certificate of Evidence of Death’. This is accepted in place of a death certificate for probate, so the will of the deceased person can be carried out even if there is an ongoing investigation with the coroner’s office.

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