- Coroners are a special type of judge. They investigate deaths suspected to be violent, unnatural or unexplained. They must also investigate deaths in detention, such as in prison, police custody or mental health settings.
- The law states that every coroner’s investigation must answer 4 questions. These questions are who is the person who died, and where, when and how they died. A coroner cannot comment on whether anyone is to blame for the death, or about any civil or criminal liability.
- The coroner’s investigation may include the a post-mortem examination. This is a detailed examination of the deceased person’s body, carried out by a specialist doctor called a pathologist. The examination is often invasive, involving medical procedures. In some cases, the examination can be done using CT or other scanning procedures. The examination may be supported by other medical tests. Sometimes, this means that samples of organs or tissues need to be taken.
- The need for a post-mortem examination and other medical tests may affect when the coroner can release the deceased person’s body to the family. However, when required, a coroner can issue an interim death certificate which can help with organising a funeral and other matters. At the end of their investigation (including the inquest if there is one), the coroner issues a final document, the record of inquest, and the death can then be registered with the registrar. The registrar can then issue the final death certificate.
- The inquest is the final stage of a coroner’s investigation. An inquest is usually a public hearing, held in a coroner’s court. In a very small number of cases, a jury sits with the coroner. At the inquest, the coroner considers all relevant evidence in order to answer the four questions of who died, and when, where and how they died.
- The investigation by the coroner may happen very quickly, and be completed within a matter of weeks. However, in some cases, the investigation may take months or years. The length of the final inquest hearing in the coroner’s court can range from less than an hour to days or weeks. In some cases, there will be one or more court preparatory hearings before the final inquest hearing.
- The coroner decides on who are the ‘interested persons’ in an investigation. The family of the bereaved are entitled to be interested persons. Interested persons can also include professionals or practitioners who were associated with the death in some way, or other representatives of the deceased person. All interested persons have certain rights during the investigation and at the inquest. These include the right to be informed about the post-mortem examination and inquest; to receive evidence relating to the investigation (this is usually called ‘disclosure’); and to ask questions of witnesses at the inquest.
- There may be an opportunity to prepare and read (or have read for you) a statement about the deceased person at the inquest. This statement is often called a ‘pen portrait’. The coroner may also allow a photo or video of the deceased to be shown at certain times during the inquest.
- In many cases, you will not need legal advice or representation if you attend the inquest as a bereaved person. However, you might want to consider appointing a lawyer if the case is complicated or if you have certain concerns about the death that you want the coroner to address. Public funding for legal advice or representation is available only in limited circumstances.
- Coroners’ courts vary widely in terms of their location, lay-out and available facilities. Many inquest hearings are run in a formal way; for example, the coroner may expect everyone to stand up when they enter or leave the court, and may want to be addressed as Sir or Ma’am. The web-pages of each coroner area, or talking to the coroner’s team, can help you to find out more about the local coroner’s court and inquest hearings.
- The coroner must come to a conclusion at the end the inquest. This includes the answers to the 4 questions of who died, and where, when and how they died. Once the inquest has concluded, the final death certificate can be issued by the registrar.
- If the coroner believes there is a risk of future deaths and that actions can be taken to prevent that risk, they must write what is known as a ‘Prevention of Future Deaths’ or PFD report. However, the coroner cannot include any comments about blame or liability in relation to the death. The coroner sends the PFD report to all individuals or organisations which are in a position to take actions. Reports and their responses are published on the judiciary.uk website.
More information on the coroner process, and links to other sources of information and support, are included throughout the Toolkit.
The Ministry of Justice has published its own Guide to Coroner Services for Bereaved People.
The Coroners’ Society lists all coroner areas in England and Wales and gives some more information about them. Our Toolkit also lists all the coroner areas along with links to the individual webpages for each area.
The Coroners’ Courts Support Service (CCSS) has a range of resources, including a website, and support via a telephone helpline or e-mail. Some coroners’ courts also have volunteers available to help people attending inquests.
INQUEST is a charity offering a range of support to those involved with the coroner service following state-related deaths, including deaths in prison, police custody or mental health facilities.
