About the coroners process

Coroners are a special type of judge. They are appointed by and based in the local authority.

The law states that a coroner must investigate deaths suspected to be violent or unnatural, or where the cause of death is not known. Coroners must also investigate deaths of people in state detention settings. This includes deaths in police custody, prisons, mental health facilities, and immigration detention centres.

There are over 450 coroners across England and Wales. These include senior coroners, a small number of area coroners and a large number of assistant coroners.

The Chief Coroner is head of the coroner service in England and Wales. The Chief Coroner is appointed by the Lady Chief Justice in consultation with the Lord Chancellor and must report annually to Parliament.

Each local coroner service is headed by a Senior Coroner. The judiciary.uk website includes a list of senior coroners across England and Wales.

All Senior Coroners are supported by a team of coroners’ officers and administrative staff. Coroners’ officers can be employed by the local authority or the local police service.

The work of a coroner’s officer is wide ranging. They are the main point of contact for bereaved people and witnesses. They are responsible for gathering evidence required for the coroner’s investigation.

In general, it may be helpful to nominate one person to communicate with the coroner’s team on behalf of the bereaved family or friends. You should led the coroner’s officer know if this nominated person has any communication or other needs, so that these needs can be met throughout the investigation, and at the inquest if is one.

As of April 2026, there are 74 coroners areas across England and Wales. Each area has its own webpages (usually hosted on a local authority website) or website. You should be able to find out general information about the coroner process and specific information about the local coroner service at these webpages/sites. However, the amount and quality of information is variable.

The Coroners’ Society is another source of information about each coroner area.

• Avon
• Bedfordshire and Luton
• Berkshire
• Birmingham and Solihull
• Black Country
• Blackpool and Fylde
• Buckinghamshire
• Cambridgeshire and Peterborough
• Carmarthenshire and Pembrokeshire
• Ceredigion
• Cheshire
• City of London
• Cornwall and Isles of Scilly
• County Durham and Darlington
• County of Devon, Plymouth and Torbay
• Coventry
• Cumbria
• Derby and Derbyshire
• Dorset
• East London
• East Riding and Hull
• East Sussex
• Essex and Thurrock
• Gateshead and South Tyneside
• Gloucestershire
• Greater Lincolnshire
• Gwent
• Hampshire, Portsmouth and Southampton
• Herefordshire
• Hertfordshire
• Inner North London
• Inner South London
• Inner West London
• Isle of Wight
• Kent and Medway
• Lancashire with Blackburn and Darwen
• Leicester and South Leicestershire
• Liverpool and Wirral
• Manchester City
• Manchester North
• Manchester South
• Manchester West
• Milton Keynes
• Newcastle Upon Tyne and North Tyneside
• Norfolk
• North London
• Northumberland
• North Wales (East and Central)
• North West Wales
• North Yorkshire and York
• Northamptonshire
• Nottinghamshire and Nottingham
• Oxfordshire
• Rutland and North Leicestershire
• Sefton Knowsley and St Helens
• Shropshire Telford and Wrekin
• Somerset
• South London
• South Wales Central
• South Yorkshire (East)
• South Yorkshire (West)
• Staffordshire and Stoke on Trent
• Suffolk
• Sunderland
• Surrey
• Swansea and Neath Port Talbot
• Teesside and Hartlepool
• Warwickshire
• West London
• West Sussex, Brighton and Hove
• West Yorkshire (Eastern)
• West Yorkshire (Western)
• Wiltshire and Swindon
• Worcestershire

The law states that a coroner must investigate deaths which are suspected to be violent or unnatural, or where the cause of death is not known. Coroners must also investigate deaths of people in state detention. This includes deaths in police custody, prisons, mental health facilities, and immigration detention centres.

The investigation is usually undertaken by a coroner in the area where the death occurred. However, in some cases the investigation may be transferred to another area. 

About a third of all registered deaths in England and Wales are referred to coroners each year. In 2024, nearly 175,000 deaths were reported to coroners in 2024; approximately 37,000 inquests were opened; and nearly 40,000 inquest conclusions were recorded.

Deaths related to alcohol, other drugs or gambling are likely to be referred to the coroner because they are often viewed as sudden or unnatural. In 2024, approximately 12% of deaths investigated by coroners were concluded to be alcohol or other drug related. Figures on gambling related deaths are not known. 

A national Medical Examiner system was introduced across England and Wales in 2024. This reviews all deaths that are not reported to the coroner. These reviews are undertaken by Medical Examiners, who are a senior medical doctor. The new system aims to make sure that the right deaths are reported to the coroner and to improve the process of death certification.

You can find out more about the Medical Examiner system in England and the Medical Examiner system in Wales.

Each coroner’s investigation is different. Some are straightforward while others are complicated and take a long time. Here, we provide an overview of the main parts and stages of the coroner process. Talking to the coroner’s team, or with your legal representative (if applicable), will give you more detail.

The overall aim of the coroner’s investigation is to gather and review all relevant evidence in order to answer 4 questions. These 4 questions are:

1. Who died.
2. When did they die.
3. Where did they die.
4. How did they die? This includes stating the medical cause of death.

One of the most important things to understand about the coroner’s investigation is that it cannot come to any decision about whether anyone is to blame or whether negligence caused the death. A coroner must also not comment on any related criminal or civil proceedings or claims.

It is also important to understand that an inquest is not a trial. This means that in the coroner’s court there are no opposing parties each presenting their case. The coroner’s inquest is an inquisitorial, fact-finding hearing. 

The first part of a coroner’s investigation is a preliminary inquiry to decide whether a full investigation is needed. If a full investigation is needed, there will often be a post-mortem examination.

The coroner can discontinue their investigation at any point if the death is found to be of natural causes. An inquest is always held if the death was violent or unnatural, or if the person died in a state detention setting (even if this was a death by natural causes).

An inquest is the final stage of a coroner’s investigation. An investigation will be discontinued before the inquest only if the coroner has decided that the death was ‘natural’ and if the death did not occur in a state detention setting.

The inquest is a fact finding hearing to review all the evidence relevant to the death, for the purpose of addressing the four questions of who died and how, when and where the person died. An inquest is usually held in public in a coroner’s court.  

If there is an inquest then it must be formally ‘opened’ by the coroner. This is usually a public hearing. This means that people such as the media or other members of the public may be there.

In some cases, the coroner holds the inquest based on documents alone. This may be conducted privately as an ‘inquest in writing’, or as a ‘documentary inquest’ held in open court. In both cases the coroner will consider only the available documents and there will be no oral evidence. For an inquest in writing, the coroner will formally open the inquest in the usual way but no further court hearing will be needed. For a documentary inquest, the relevant parts of the written evidence that form the basis of the coroner’s findings will be read out in open court as will the coroner’s factual findings, determinations and conclusion.

If the inquest is straightforward, it be may be completed immediately after it has been opened. In other cases, the coroner may open and then immediately adjourn the inquest to a later date. This is usually because more time is needed to gather all the information required for the inquest.

The coroner’s team should tell you about the opening of the inquest. You do not have to attend if you do not want to. You may want to let the coroner’s team know if you want to know when the inquest is opened, and if you want to attend.

Article 2 of the European Convention on Human Rights (ECHR) provides that “everyone’s right to life shall be protected by law”. In England, Wales and Northern Ireland, a coroner’s inquest is how the UK ordinarily discharges its obligation to investigate potential breaches of Article 2 by the state. The circumstances when an inquest will be an Article 2 inquest are rare.

The main difference between an Article 2 investigation (including the inquest) and other investigations is that the coroner must consider the wider circumstances of the death. The exact shape of this broader investigation will be decided by the coroner on a case-by-case basis. However, even in an Article 2 inquest a coroner cannot make any statement about blame or liability in the death.

The coroner usually decides whether it is an Article 2 investigation before the final inquest hearing. All deaths in state detention that are not a result of natural causes must be subject to an Article 2 investigation.

A coroner investigates deaths of British nationals abroad, if the death was sudden, violent, unnatural, or the cause is unknown. The body must be repatriated (brought back to England or Wales) before the coroner carries out their investigation. The coroner usually does not carry out an investigation if the body has already been cremated abroad.

The investigation is normally undertaken by a coroner in the area of England or Wales where the deceased, or their immediate family, was living.

The FCDO (Foreign, Commonwealth & Development Office) or local consulate can provide help and information when someone dies abroad.

Guidance for coroners states that the whole investigation, including the inquest if there is one, should be concluded within 6 months of the death being referred to the coroner. However, many investigations take longer than this. Unfortunately, some may not be completed for a considerable period of time.

There are a number of reasons for such delays. In many cases, delays are linked to the complexity of the investigation and all the evidence that must be gathered. This can include waiting for reports from pathology services or other experts or witnesses. In some cases, there are delays until investigations by other organisations have been completed.

Lengthy investigations and delays can be extremely difficult for the bereaved. They may lead to delays in registering the death, holding a funeral or dealing with administrative matters following the death.

The law states that the coroner has temporary legal control of the body of the person who has died while they are carrying out their investigation.

You may be asked to go to a mortuary to formally identify the deceased’s body. If this is not needed, you may still want to view the body before it is taken to a funeral home. The coroner’s team will help and support you with this. In some cases, you may not be allowed in the same room as the body, but may look through a glass window. If you are in the same room, you may be asked not to touch the body. This is usually because further examination is needed as part of the investigation.

The coroner’s team or other professionals may advise you not to see the body. This is usually because they believe it will be very upsetting. However, this should be discussed with you so that you can decide what you want to do. 

If there are any faith or other needs regarding the handling of the body, you should talk to the coroner’s team. They will try to meet these needs wherever it is possible to do so. If it is not possible, they will explain this to you, and support you as much as they can.

It is a legal requirement to formally register the death with the registrar. However, this cannot happen until the coroner has discontinued or completed their investigation and confirmed the cause of death. Where necessary, the coroner can issue formal documents that can help with registering the death and holding a funeral.

The coroner must release the body as soon as possible after the post-mortem examination (if there has been one) and any other relevant examinations have been completed. The coroner’s team should keep in touch with you about the release of the body and any delays linked to this.

If the coroner decides that there is no need to investigate a death, then they will complete Form 100 A and send it to the registrar so that the death registration process can be completed.

If the coroner asks for a post-mortem, but no tests in addition to this, then a Burial Order or Cremation Form 6 can be issued. The coroner will notify the registrar of this.

If the coroner discontinues their investigation, after a post-mortem examination and any other tests, then they will issue a Cremation Form 6 (if required) and Form 100 B. This notifies the registrar that a post-mortem examination has been completed, but no further action is needed. This allows the registrar to complete the death registration process.

If the coroner decides that an inquest is needed, but the deceased’s body can be released, then they will issue a Burial Order or Cremation Form 6 to the registrar. This allows the death registration process to be progressed.

At the end of an inquest hearing, then the coroner will complete the Record of Inquest, and this document is provided to the deceased’s family. This includes the 5 boxes that answer the statutory questions as set out in Section 5(1) of the Coroners and Justice Act 2009, and fulfils the requirements of the registration acts. This document can be used for administrative functions arising from the death and the deceased’s estate. 

The coroner also completes Form 99, the Certificate after Inquest. This includes the details in the Record of Inquest, along with other statutory details required by the registrar. Form 99 is sent to the registrar, and the death registration process can be completed.

A post-mortem examination is carried out in about 50% of all coroner investigations. A post-mortem (PM) examination is sometimes called an autopsy. The coroner decides whether a PM examination is needed.

A PM is performed by a specialialist doctor called a pathologist, supported by a team of other staff. A PM is a detailed medical examination of the body in order to find out the cause of death.

In some cases, the PM examination will be an invasive or surgical procedure. However, in other cases a non-invasive CT or other scan may be possible. Non-invasive PM examinations are not available or possible in all coroner areas. The coroner’s team should talk to you about all of these things.

The coroner may ask for other medical tests in addition to or instead of a PM. Toxicology tests check whether any drugs or chemicals have played any part in the death. Histology tests examine tissue samples taken from the body to see if certain diseases or other factors played any part in the death. Toxicology and/or histology tests are quite common following alcohol or other drug related deaths.

Your consent is not needed for a PM examination. If you are next of kin or an interested person, you have the right to be told that a PM examination is needed, and when this will take place. You can also ask for a doctor to be present at the PM on your behalf.

The consent of family members is generally needed for the retention of organs or tissue samples after a PM (this is under the Human Tissue Act 2004 in England, Wales, and Northern Ireland). The coroner must talk to you about what will happen to tissue and organ samples when they are no longer needed.

If there are any faith or other needs regarding the handling of the body, then you should talk to the coroner’s team. The coroner and the pathologist will try to meet these needs wherever it is possible to do so. If it is not possible, they will explain this to you, and support you as much as they can.

It is usually possible for the body to be returned to the family after the PM examination. However, in some cases the body needs to be kept for longer. For example, if further tests may be needed.

The pathologist must write a detailed report about the examination of the body. This report is usually one of the most important parts of the evidence gathered by the coroner. The review of the pathologist’s report is also an important part of the inquest if there is one. There will be additional reports about any other medical tests that the coroner has requested. If the coroner has listed you as an interested person, then you have the right to receive a copy of these reports. It can be difficult and distressing to read such reports, so you may want to ask for support if you want to read the reports.

In some cases, there will be one or more hearings before the final inquest. These are commonly called ‘pre-inquest review’ hearings (PIR/PIRH). Like the final inquest hearings, these are public hearings, and are usually held in the coroner’s court. It is up to you to decide if you want to attend these hearings.

The aim of these hearings is to prepare for the final inquest. This includes discussing the scope of the investigation, the evidence that will be gathered and considered, and which witnesses will attend to give oral evidence. The final decision on all of these matters will be made by the coroner. Practical matters such as the date, location and estimated length of the final inquest hearing may also be discussed.

The final inquest hearing usually takes the form of a public hearing in a coroner's court. However, inquests ‘in writing’ were introduced in June 2022. A coroner may decide to conduct an inquest in writing for a number of reasons. For example, if there appears to be no or little risk of disagreement about the inquest conclusion, if there is no public interest to be gained by holding the hearing in a public court, and if all interested persons agree. If the coroner has listed you as an interested person, you should be asked whether you agree for the coroner to hold an inquest in writing.

Inquests held in the coroner’s court, are public hearings, which means that anyone can attend. There are exceptions to this as explained here.

Inquests vary widely in length – from less than an hour to days, weeks or even months.

Inquests also vary in terms of how many people attend. Other people at an inquest can include witnesses, lawyers, people associated with the deceased person, the media, and other members of the public.

It is possible for some people, including witnesses and bereaved people, to attend the inquest remotely, such as by video link. This is often for practical reasons. The coroner decides who can attend the inquest remotely. If you would like to attend the inquest remotely, then you should talk to the coroner’s team. If you are attending remotely, it’s a good idea to make sure you will be somewhere with good wi-fi so you can be confident you will not keep dropping out of the hearing.

A jury is part of an inquest in approximately 1% of cases. There will always be a jury for inquests that consider non-natural deaths in any state detention setting; if the death is associated with an act or omission of a police officer; or if the death is associated with a ‘notifiable accident, poisoning or disease’ (for example, a death in the workplace). It is up to the coroner to decide if there will be a jury in other cases.

An inquest jury is made up of a group of randomly selected members of the public. Members of the jury can ask questions of witnesses. At the end of the inquest, guided by the coroner, the jury must come to a majority conclusion on how the person died. Like the coroner, the jury cannot make any statement or conclusion about blame, liability or negligence associated with the death.

The inquest conclusion is given by the coroner, or the jury where applicable, at the end of the inquest. (It used to be called the ‘verdict’.) The coroner will summarise the key points from the inquest, go through the answers to the 4 questions that must be answered, and give the conclusion. In some cases, there may be a break, with the coroner giving their summary and conclusion later in the day or a different day.

The coroner has a number of ‘short-form’ conclusions that they can use. These include: accident or misadventure; alcohol and/or drug-related; industrial disease; lawful or unlawful killing; natural causes; road traffic incident; suicide.

A coroner may also issue a ‘narrative’ conclusion alongside or instead of a short-form conclusion. A narrative conclusion allows the coroner (or the jury) to give more detail about the death. They are more common in ‘Article 2’ inquests, or where the investigation has been more complicated.

At the end of the inquest, the coroner will detail their conclusions in the ‘Record of Inquest’. This includes the answers to the 4 questions that must be answered (who died, when they died, where they died, and how they died). The coroner will then notify the Registrar, and this means that the Registrar can issue the final death certificate.

If the coroner has listed you as an interested person, then you will receive a copy of the final Record of Inquest. You can also ask for a copy of the audio recording of the inquest hearing, and any pre-hearings if these were held. However, you may have to pay for the recordings.  

A Prevention of Future Deaths (PFD) report is also known as a Regulation 28 report. The coroner must write such a report if their investigation leads them to believe that there is a risk of future deaths and that actions can be taken to prevent or reduce this risk. About 2% of inquests give rise to one or more PFD reports. A coroner may choose to hear and give weight to representations by interested persons about whether a PFD report should be issued

A PFD report usually follows a particular format. The coroner should explain their concerns and make suggestions about what needs to happen to prevent future deaths. The coroner cannot make recommendations on what specific actions are needed, or make any comments about blame, negligence or liability in relation to the death.

A PFD report can be sent to any individual or organisation who the coroner believes is in a position to take the suggested actions. Most frequently, reports are addressed to government departments, local authorities, and health, social care and criminal justice agencies such as NHS Trusts, police forces or prisons. Those who receive a PFD report must respond within 56 days. The response must explain how the concerns raised by the coroner have been or will be addressed.

All PFD reports and their responses are published on the Judiciary website. The Preventable Deaths Tracker is another helpful resource.

If you have a complaint about any aspect of the coroner’s investigation or inquest, you should approach the coroner’s team first to see if your complaint can be resolved informally.

If you want to complain further about the handling of the investigation, you should contact the local authority. You should then go to the Local Government and Social Care Ombudsman if you are still not satisfied. However, the Ombudsman cannot review the conclusions made by the coroner.

Complaints that are specifically about the behaviour of the coroner should be taken to the Judicial Conduct Investigations Office.

If you want to challenge the coroner’s conclusion to the inquest, there will need to be a judicial review by a senior judge in the High Court. However, there are complexities and limitations associated with the judicial review process. The focus of any judicial review will be on the way the decision was made, and not the conclusion itself. The review must be held within 3 months of the original decision. There is no guarantee that an application for such a review will be successful. There is more information about this process here.