Coroners - sudden death investigations

Coroners and Inquests

If the death is one which the coroner must investigate:

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Organ Donation

If you wish to consider organ donation, you will need immediate advice.  This can be sought from a hospital or doctor, or from the coroner's office.  The coroner must be told and must agree before organs can be removed.  In some cases, organ donation may not be possible for medical reasons, or because of the delays when a death has to be registered.

If you are the next of kin, you have the right:

  • to be told in advance the date, time and place of the post mortem examination unless this is not practicable or would unduly delay the examination;
  • to have your choice of medical representative present at the post mortem;
  • to be told the date, time and place of the inquest if one is needed;
  • to question witnesses at the inquest, or have a legal representative to do so on your behalf.

You may also:

  • ask the Coroner for reasonable access to see the body, if you wish, before it is released for the funeral;
  • ask the Coroner for a copy of the post mortem report, but a fee may be payable;
  • ask the Coroner about a separate post mortem.  This examination would be at your own expense and by a pathologist of your choice.

Other persons with an interest may have similar rights.

An inquest is not needed in every case.  Where it is, a short preliminary hearing will take place within a few days.  The full inquest will usually be resumed in due course.

1. Who are the Coroners?

Coroners are independent judicial officers in England and Wales who must follow laws which apply to Coroners and inquests.  Each Coroner has a deputy and one of them must be available at all times to deal with matters relating to the inquests and post mortems.  Coroners are usually lawyers but may be doctors.  They are appointed and paid by the local authority.

2. What do Coroners do?

Coroners inquire into deaths reported to them which appear to be violent, unnatural, or of sudden and unknown cause.  The Coroner will seek to establish the medical cause of death; if the cause remains in doubt after a post mortem, an inquest will be held.
Taking the body abroad or bringing it back to this country.  If you wish to take the body abroad, you must give written notice to the Coroner.  The Coroner will tell you within four days whether further enquiries are needed.
If you wish to bring the body back to England or Wales, the Coroner may need to be involved.  In certain circumstances, an inquest may be necessary.  You can ask for advice from your local Coroner's office.

3. What is the role of the Coroner's Officer?

Coroners' Officers, who may be police officers, work under the direction of Coroners and liaise with bereaved families, police, doctors and funeral directors.

4. Are all deaths reported to the Coroner?

No.  In most cases, a GP or hospital doctor can certify the medical cause of death and the death can be registered by the Registrar of Births and Deaths in the usual way.  However, registrars must report deaths to the Coroner in certain circumstances.  For example: If a doctor cannot give a proper certificate of a cause of death; if the death occurred during an operation; if the death was due to industrial disease; or if the death was unnatural or due to violence, or in other suspicious circumstances.

5. What is a Post Mortem examination

A post mortem is a medical examination of a body carried out for the Coroner by a pathologist of the Coroner's choice.  Coroners will give notice of the need for a post mortem unless this is not practicable or would unduly delay the examination.  The consent of the next-of-kin is entitled to be represented at the examination by a doctor of their choice.   You can ask the Coroner for a separate post mortem examination, at your own expense and by a pathologist of your choice.  If the Coroner has released the body, you will need the consent of the executor of the dead person's estate.

6. Post Mortem Report

This report gives details of the examination of the body.  It may also give details of any laboratory tests which have been carried out.  Copies of the report will normally be available to the next-of-kin and to certain other relatives.  A fee may be payable.

7. Medical Records

Medical records remain confidential after death.  Coroners are entitled to request medical information that is relevant and necessary to their enquiries.

8. When can the funeral be held?

If a post mortem reveals that the death was due to natural causes and that an inquest is not needed, the Coroner will release the body and you can register the death.  The funeral can then take place.  If there is to be an inquest, the Coroner can normally issue a burial order or cremation certificate after the post mortem is completed.  If charges have been brought against somebody for causing the death, it may be necessary to have a second post mortem or further investigations, and the release of the body and the funeral arrangements will be delayed.

9. Issue of the Death Certificate

If the death was due to natural causes, the Coroner will inform the Registrar and the death can be registered and a death certificate issued.  But, if there is to be an inquest, an interim certificate of fact of death can be issued by the Coroner to assist in the administration of the estate.  When the inquest is completed, the Coroner will notify the Registrar.  A death certificate can then be obtained.

10. What is an inquest?

An inquest is an inquiry into who has died and how, when and where the death occurred.  An inquest is not a trial; the Coroner must not blame anyone for the death.
An inquest is usually opened primarily to record that a death has occurred and to identify the dead person.  It will then be adjourned until any police enquiries and the Coroner's investigations are completed.  The full inquest can then be resumed.

11. Attendance at an inquest

When the Coroner's investigations are complete, a date for the resumed inquest is set and the people entitled to be notified will be told, if their details are known to the Coroner.  Inquests are open to the public and journalists are usually present.

12. Witnesses called to give evidence

Coroners decide who should give evidence as a witness.  Anyone who believes they may be able to help can offer to give evidence by informing the Coroner.  Anyone who believes a particular witness should be called should inform the Coroner.  Witnesses can be compelled to attend.

13. Questioning of witnesses

Witnesses will first be questioned by the Coroner and there may be further questions by 'properly interested persons', or their legal representatives.  Questions must be relevant to the purpose of the inquest.
Persons with a 'proper interest' include:

  • parent, child, spouse, or legal personal representative of the deceased;
  • person who may have a responsibility for the death;
  • a beneficiary from an insurance policy relating to the deceased;
  • representatives of any relevant insurance company;
  • a representative from a relevant trade union (if the death arose in connection with the person's employment or was due to industrial disease);
  • certain inspectors or representatives of enforcing authorities or persons appointed by a government department;
    the police;
  • any other persons the Coroner considers to have a legitimate interest for the purposes of the inquest.

14. Inquests with a Jury

The inquest will be held with a jury if the death occurs in prison, in custody, at work or if further deaths may occur in similar circumstances.  In these cases, the Coroner decides matters of law and the jury decides the verdict.

15. Questioning of witnesses

Inquests do not determine blame and the verdict must not identify someone as having criminal or civil liability.  Possible verdicts include: natural causes, accident, suicide, unlawful or lawful killing, industrial disease, and open verdicts (where there is insufficient evidence for any other verdict).   The Coroner may also report the death to any appropriate person or authority, if action is needed to prevent more deaths in similar circumstances.

16. What can you do if you are dissatisfied with the outcome of an inquest?

It is possible to challenge Coroners' decisions or verdicts, but the grounds for doing so are complex and need explanation by a lawyer with expertise in this area of law.  An application for judicial review can be made, but this must be done within three months of completion of the inquest.  An application for a fresh inquest can be made at any time.  All such applications should be made as soon as possible.

17. Inquest records

Notes of Evidence at an inquest can be seen by properly interested persons, or copies may be obtained on payment of a fee.  The record may be a transcript from a tape-recording or the Coroner's own notes.  These notes may not be a full, verbatim record.

18. Criminal proceedings

If a charge is to be heard in the Magistrates' Court, the inquest should be completed before the court hearing.  If a charge is heard in the Crown or higher courts, the Coroner is advised of the outcome, the Registrar is informed and the inquest is not normally re-opened.

19. Civil proceedings

Civil proceedings (for example, for compensation) are not dependent on the outcome of an inquest or criminal proceedings.  Most must be started within three years of a death.  You will need a lawyer's advice about time limits and the procedures that apply.
Evidence given at an inquest, or during criminal proceedings, may help families understand what has happened.  It may also assist in claims for compensation.  You may wish to consider seeking legal advice before the inquest.

20. Is Legal Aid available?

Legal Aid is not normally available to fund legal representation at an inquest.  Legal advice under the 'Green Form' scheme may be available for those who are financially eligible.

21. The Coroner's Office

The telephone number of the Coroner's office can be obtained from the police.  The Coroner's Officer can be contacted for further information.

22. Department of Work and Pensions 

This information is reproduced with kind permission of the Home Office.