Information & Support
To support practically and emotionally the family and other witnesses attending a Coroner’s Court.
An Inquest can be a traumatic experience for anybody involved. Our aim is to help, guide and support everyone attending an Inquest. The CCSS’s trained volunteers will guide people through the often complicated and bewildering process and explain the Inquest procedure to you, helping you have a much better understanding of your role with this often unfamiliar environment.
The volunteers at Court meet anxious people every day from many different backgrounds, circumstances and lifestyles and understand the importance of supporting everyone attending with a non-judgmental attitude.
If you would like to talk to a volunteer before the day of the Inquest we have a telephone helpline available Mon – Fri 9.00 am – 7.00 pm and Saturday 9.00 am – 2.00 pm. Please call 0300 111 2141 or e-mail firstname.lastname@example.org
We can also signpost you to other organisations that may be able to help in the longer term.
Bereavement is a universal experience yet it will be unique to each one of us and it is natural to feel intense grief after someone dies. Usually people are resilient and manage to cope with difficult experiences but, when someone close to us dies, we can’t imagine living without that person in our lives and the loss can be a physical pain. The pain can hurt so much that we just want to make it stop. Family and friends can often feel helpless when seeing a loved one in so much distress. People often say they have:
- Strong feelings of yearning or longing for the person; it’s almost like the death just happened;
- Frequent intense loneliness or feeling like life is empty or meaningless;
- Thoughts of the person seem to fill your mind or intrude on your thoughts when you are doing things so that it might be difficult to concentrate
Some typical reactions to the loss are:
- Troubling feelings of being shocked, stunned, dazed or numb;
- Feelings of disbelief or an inability to accept what happened even though you know it’s true for example you know the person died but it doesn’t seem possible
Sometimes this can negatively impact on the natural grieving process and interfere with how you are coping with the loss. It can also feel like there is little or no possibility of a meaningful future.
Bereavement and trauma can affect people in different ways and it is not unusual to feel shock, denial, anger, sadness and despair at any time. You may lose confidence, feel powerless and that the future holds no hope. You may feel isolated and anxious and it is possible your physical health may suffer. All these are common reactions and some people find that attending the Inquest can “bring it all back” and their grief is overwhelming.
There is no “normal” response to the death of a loved one and nor is there a timeline as to when you should “recover”. Sometimes it is just about acceptance of what has happened and getting through one day at a time when all seems too much to bear. You may also have to take on additional responsibilities that are new to you.
Whereas, in time, we would normally adapt to the loss and come to terms with it, this can be more difficult when there is a Coroner’s investigation involved.
We understand that a Coroner’s Court can be a bewildering place to attend. As a bereaved family member or a witness, it is an event of which you may have little or no understanding. The difficult circumstances that surround a death requiring an Inquest already complicates the grieving process and can often delay it. You may also feel like you have been waiting and hoping for something to change once the Inquest is over.
The vision of the CCSS is to have volunteers available at every Court in England and Wales. It is our hope that no one should attend an Inquest without the practical and emotional support our volunteers can provide.
These are some of the experiences of others who have received our help:
“It’s a strange and scary experience, being at an inquest for you own relative, and you’re at a very vulnerable and anxious stage. So, it was very, very nice indeed to have someone to greet us and take care of us and explain the process and answer any questions we had.”
“The volunteer spent a good deal of time discussing forthcoming arrangements and answering any questions leading up to the event. She even arranged for my sister and I to visit the Coroner’s Court ahead of the inquest date so my sister could familiarise herself with the setting. Her support and guidance helped keep my sister focussed whilst her kind manner kept things steady.”
“The volunteer was so helpful in explaining the procedure and looking after us throughout and afterwards. We couldn’t have got through it without her.”
“Following the death of my mother in hospital, the Coroner decided that an Inquest should be held.
My four siblings and I received leaflets from the Court outlining the procedure, but were all equally daunted at the prospect of attending an Inquest, particularly as we were emotionally tender having lost Dad as well shortly before the Inquest.
On arrival at the Court we were greeted by two volunteers from the Coroners’ Courts Support Service (CCSS), who made us all feel most welcome and at ease. They explained in simple terms the Inquest procedures, described the Courtroom, showed us the facilities, lifts, stairs, toilets etc. advised us on how to address the Coroner, take the oath in the Witness Box and answered any questions we had – no matter how silly they may have seemed.
During the Inquest, there was a volunteer in the Court with us throughout and it was most reassuring knowing that we could get their support and advice should we need it.
The CCSS is a wonderful charity, providing a much-needed service, at a time of stress and upset. We couldn’t have got through the day without them.”
Coroners’ Courts across the UK
The map below shows all the coroners’ courts across the UK
The Coroner’s Office
The Courthouse, Old Weston Street
T: 01275 461920
Bedfordshire and Luton
The Coroner’s Office
The Court House
T: 0300 300 8383
The Coroners Office
T: 0118 937 2300
Birmingham and Solihull
50 Newton Street,
Birmingham, B4 6NE
T: 0121 303 3920
Smethwick Council House
T: 0121 569 7200
Blackburn, Hyndburn and Ribble Valley
The Coroners Office
Blackburn Enterprise Centre
T: 01254 505000
Blackpool and Fylde
Blackpool and Fylde Coroner’s Office
T: 01253 477128
Brighton and Hove
The Coroner’s Office
Lewes Road, Brighton,
East Sussex, BN2 3QB
T: 01273 292046
29 Windsor End
Beaconsfield (Old Town)
T: 01494 475205
Cambridgeshire & Peterborough
Senior Coroner’s Office (Peterborough)
33 Thorpe Road
T: 0345 0451364
Carmarthenshire and Pembrokeshire / Sir Gaerfyrddin a Sir Benfro
Pembrokeshire, SA73 3JW
T: 01646 698129
Central and South East Kent
Kent ME15 0SB
T: 03000 41 05 02
New King’s Court
Eastleigh, SO53 3LG
4 Lindum road
10 Queen Street
T: 01522 555778
Brunton & Co.,
6 Upper Portland Street,
Ceredigion SY23 2DU
T: 01970 612567
The Coroner’s Office
The Town Hall
T: 01925 444216
City of London
City Coroner’s Office,
78-83 Upper Thames Street,
London EC4R 3TD
T: 020 7332 1598
The Coroner’s Office
14 Barrack Lane,
Truro, TR1 2DW
T: 01872 324438
County Durham and Darlington
HM Coroner’s Office,
PO Box 282,
T: 03000 265556
Little Park Street
Coventry, CV1 2JX
T: 024 7683 3345
The Coroner’s Office
Cockermouth CA13 9PT
T: 01900 706902
Derby and Derbyshire
St. Katherine’s House,
St. Mary’s Wharf, Mansfield Rd,
Derby, DE1 3TQ
T: 01332 343225
The Coroner’s Court,
Bournemouth, BH1 1PA
T: 01202 454910
East Lancashire Coroner’s Office
Burnley BB10 4AB
T: 0300 123 6705
London, E17 8QP
T: 020 8496 5000
East Riding and Hull
The Coroner’s Office and Court,
Alfred Gelder Street
Hull , HU1 2AA
T: 01482 613009
28/29 Grand Parade,
St Leonard’s on Sea
East Sussex, TN37 6DR
T: 01424 723030
Essex County Council
A Block Ground Floor
Victoria Road South
Essex CM1 1QH
T: 0333 0135 000
Exeter and Greater Devon
Devon County Court
T: 01392 383636
Gateshead and South Tyneside
35 Station Road,
Tyne and Wear NE31 1LA
T: 0191 483 8771
Gloucester GL4 3DJ
T: 01452 305661
11 Clytha Park Road,
Newport NP20 4PB
T: 01633 264194
Offices of DMA
155 York Road,
T: 01429 274732
St Owen Street
T: 01432 260565
The Old Courthouse
St. Albans Road East,
Herts. AL10 OES
T: 01707 292707
Inner North London (Camley Street)
St Pancras Coroner’s Court,
T: 020 7974 4545
Inner North London (Poplar High Street)
Poplar Coroner’s Court
127 Poplar High Street
T: 020 7974 4545
Inner South London
1 Tennis Street,
London, SE1 1YD
T: 020 7525 4200
Inner West London
Westminster Coroner’s Court,
65 Horseferry Road,
London, SW1P 2ED
T: 020 7641 1212
Isle of Scilly
Coroner’s Torbay office
1 Park Steet
T: 01803 380705
Isles of Wight
The Coroner’s Office,
3-9 Quay Street,
Isle of Wight, PO30 5BB
T: 01983 535100
Leicester City and South Leicestershire
2nd Floor, Town Hall,
Town Hall Square,
Leicester, LE1 9BG
T: 0116 225 2534
Liverpool and Wirral
HM Coroner’s Court,
Gerard Majella Courthouse,
Liverpool, L5 2QD
T: 0151 233 5770
HM Coroner’s Office & Court
PO BOX 532
Manchester Town hall
T: 0161 219 2222
T: 01706 924815
Mount Tabor Street,
T: 0161 474 3993
HM Coroner’s Court
Howell Croft North,
Bolton, BL1 1QY
T: 01204 338799
Mid Kent and Medway
Kent Register Office
The Archbishop’s Palace
Kent ME15 6YE
T: 03000 41 05 02
1 Saxon Gate East
Central Milton keynes
T: 01908 691691
Newcastle Civic Centre,
Newcastle upon Tyne NE1 8QA
T: 0191 277 7280
69-75 Thorpe Road
T: 01603 276493
110 Whitworth Road
T: 03000 111222
North East Hampshire
Hampshire RG21 4AN
T: 01256 478119
North East Kent
5 Lloyd Road,
Kent, CT10 1HX
North Lincolnshire and Grimsby
Cleethorpes Town hall
T: 01472 324005
29 Wood Street
Barnet EN5 4BE
T: 020 8447 7680
17 Church Street,
T: 01289 304318
3 Stanley Street, Blyth,
T: 01670 354777
North Wales (East and Central)/ Gogledd Cymru (Dwyrain a Chanol)
T: 01824 708047
North West Kent
The White House,
Kent DA13 0JB
T: 01474 815747
North West Wales / Gogledd Orllewin Cymru
Maes Glas 37 Y Maes,
Gwynedd LL55 2NN
T: 01286 672804
North Yorkshire (Eastern)
T: 01653 600070
North Yorkshire (Western)
21 Grammar School Lane
T: 01609 533 843
Nottinghamshire and Nottingham
Office and Main Court,
The Council House,
Old Market Square,
Nottingham NG1 2DT
T: 0115 841 5553
Oxfordshire Coroner’s Service,
Oxford Registration Office,
Second Floor, 1 Tidmarsh Lane,
Oxford, OX1 1NS
T: 0845 605 4174
Plymouth Torbay and South Devon
Coroner’s Torbay office
1 Park Steet
T: 01392 383636
Portsmouth and South East Hampshire
Portsmouth P01 2AB
T: 023 9268 8326
Preston and West Lancashire
2 Faraday Court
Fulwood, Preston PR2 9NB
T: 01772 703700
Rutland and North Leicestershire
T: 0116 305 7732
Sefton, St Helens and Knowsley
Southport Town Hall
Southport, PR8 1DA
Shropshire, Telford and Wrekin
HM Coroner’s Service
Shrewsbury SY3 8HQ
22 Bath Street,
Somerset, BA11 1DL
Blackbrook Park Avenue,
Somerset, TA1 2PG
Office of HM Coroner
Unit 1, Gilbert Drive Endeavour Business Park
Boston, Lincolnshire PE21 7TQ
St Blaise Buildings,
Bromley Civic Centre,
Bromley BRI 3UH
3 Stanley Street,
Northumberland NE24 2BS
No 1 Staffordshire Place
Stafford ST16 2LP
South Wales and Central
The Coroners Office
1st Floor Rock Grounds
South Yorkshire (East)
The Crown Court College Road
South Yorkshire (West)
Sheffield, S3 7ES
Southampton and New Forest
12-18 Hulse Rd
Stoke on Trent and North Staffordshire
547 Hartshill Road,
Stoke-on-Trent, ST4 6HF
Suffolk IP1 5PE
Office of HM Coroner
Civic Centre, Burdon Road
Sunderland, SR2 7DN
HM Coroner’s Court
Surrey GU22 7AP
Swansea and Neath Port Talbot/ Abertawe a Chastellnedd Port Talbot
Swansea, SA1 3SN
Warwickshire Justice Centre
25 Bagleys Lane,
London, SW6 2QA
3 Orchard Street
West Sussex PO19 1DD
West Yorkshire (Eastern) - Northgate
Wakefield, WF1 3BS
West Yorkshire (Eastern) - Belgrave Street
Leeds, LS2 8DD
West Yorkshire (Western)
Bradford, BD1 1LA
Wiltshire and Swindon
26 Endless Street
Salisbury, SP1 1DP
The Court House,
Stourport on Severn,
Worcs. DY13 8XE
York, YO1 7PP
The close relatives of the person who has died have a special status in coronial law. They are known as properly interested persons (PIPs) and have the right to become involved in the inquest in certain ways.
A deceased person’s husband, wife, civil partner, parent or child is automatically a PIP. The Coroner will also usually regard brothers, sisters and long-term partners as PIPs, and if the next of kin is a more distant relative such as a grandchild, the Coroner will usually grant them that status as well.
Before the inquest hearing, PIPs can request copies of all the reports and statements, as previously explained.
At the hearing, PIPs may ask questions of the witnesses. The Coroner will let them know when they may do so. The usual format is that the witness will go through their statement or report, the Coroner will ask their questions and then give PIPs the opportunity to ask theirs. Questions must be relevant to the remit of the Inquest but if you are unsure if a question is relevant or not the Coroner will let you know if it is not relevant.
PIPs have the right to be legally represented if they choose but in most cases there is no financial help with this.
After the inquest, PIPs may request copies of the reports and statement if they did not obtain them beforehand.
Other people present at the inquest may also be granted PIP status for different reasons. If so, they will also be given the opportunity to ask questions.
Others may be student nurses or law students who are observing as part of their course. Press would also be in Court and they report on the case and may approach your family for a statement but there is no obligation for you to talk to them.
A witness will usually be asked to attend the inquest voluntarily, but if they do not agree and their evidence is crucial, the Coroner may issue a witness summons to compel their attendance. If the witness then does not attend he/she may be arrested, brought before the Coroner and charged with contempt of Court.
Coroners inquire into violent and unnatural deaths, sudden deaths of unknown cause, and deaths that have occurred in prison and certain other categories. A coroner’s authority to inquire flows from the report of the fact that a body lies within the Coroner’s Jurisdiction; it does not depend on where the death occurred. The Coroner’s inquiries may take one of several forms and may result in the holding of an inquest. It is a Coroner’s duty at an inquest to establish who the deceased was, how, when and where the deceased came by his or her death. After an inquest the Coroner will send the necessary details to the Registrar of Births and Deaths so it can be registered when it occurred in England and Wales. An inquest is not permitted to determine or appear to determine criminal liability by a named person or civil liability. It is about what happened, not who was responsible for what happened, for which the civil and criminal courts have jurisdiction. It is also about how someone died, not why he or she died. In some cases a death may be referred by the Coroner to the police for investigation on his behalf. In other cases a separate investigation into a death may be undertaken by an independent organisation such as the Health and Safety Executive, the Prisons and Probation Ombudsman, the Care Quality Commission, the Independent Police Complaints Commission, the Air Accident or Marine Accident Investigation Branch, etc. The Coroner will be given the results of their investigation. Coroners also have jurisdiction over Treasure
The Coroners Support Officer involves processing inquest files that the Coroner needs court sessions for. Instructions will be given to the Coroner’s Support Officer on what is needed, you will look at the files to ascertain what is required and or missing etc. and present to the Coroner. The Coroner’s Support Officer will work in an environment involving deaths, they take statements over the phone or in person to gain details about the life of the deceased. Dealing with grieving families on every category of death including children. As part of the role, Coroners Support Officers meet with the family when required to identify the deceased and take statements from the family.
The clerk ensures the smooth running of the Inquest and works under the direction of the Coroner, swearing in witnesses etc (similar role to that of the Coroner's Officer if the Coroner's Officer wasn't in Court).
Volunteers support bereaved families and witnesses who may be experiencing a wide range of emotions and feelings when they attend the Coroner’s Court. Volunteers undertake Pre-Inquest familiarisation of the Coroner’s Court and explain the processes and procedures to families and witnesses. They accompany families and witnesses into court and once the Inquest has concluded will allow them time for recovery in a quiet place, if available, and ensure they have received all the necessary information from the Coroner’s Officer.
Volunteers listen to and empathise with concerns and anxieties of the families and witnesses attending an Inquest.
What happens when someone dies?
When a person dies in England or Wales, the death has to be registered. This is so even if they are a visitor to the country. There are only two ways in which the death can be registered. The first is if a doctor was in attendance during the final illness of the person who died and is able to issue a medical certificate of the cause of the death in a form acceptable to the local Registrar of Deaths. The second, if the first cannot be achieved, is for the death to be reported to a Coroner.
When a death is reported to a Coroner there are three ways in which s/he can deal with it. First, s/he might be able to authorise burial following a discussion with the doctor who attended the individual and it does not involve a post-mortem examination.
Secondly, where someone dies suddenly and the cause is unknown, the Coroner may order a post-mortem examination (syn. autopsy or necropsy) by a pathologist whom s/he selects. If that examination yields a cause of death that is entirely natural, and there are no other circumstances that would make the death an “unnatural” death, the Coroner may issue the paperwork to the registrar of deaths that allows burial or cremation to take place. In such a case there will usually be no Inquest hearing.
The third method for the Coroner is to conduct an Inquest into the death. His or her duty to do so arises from law which states:
Where a Coroner is informed that the body of a person (“the deceased”) is lying within his district and there is reasonable cause to suspect that the deceased:—
- has died a violent or an unnatural death;
- has died a sudden death of which the cause is unknown; or
- has died in prison or in such a place or in such circumstances as to require an Inquest under any other Act,
then, whether the cause of death arose within his district or not, the Coroner shall as soon as practicable hold an Inquest into the death of the deceased either with or, subject to subsection, without a jury.
When is a death reported to a Coroner?
Any death that is violent or unnatural must be reported to the Coroner. The term “unnatural” carries a wide meaning. It is not enough to say that someone has died of natural causes – even so the case may require an Inquest if the surrounding circumstances are such as to make it unnatural or violent. The following list helps explain the types of death that will require a report to the Coroner, but the list is illustrative, not exhaustive.
A death should be reported to HM Coroner if*:
- The medical cause of death is unknown
- The death cannot readily be certified as being due to natural causes
- The deceased was not attended by a doctor during his or her last illness or was not seen within the 14 days prior to death
- There are any suspicious circumstances or any history of violence
- The death may be linked to an accident (whenever and wherever it might have occurred)
- The death may be due to acute alcohol poisoning
- There is any question of self-neglect or neglect by others
- The death has occurred or the illness has arisen during or shortly after detention in police or prison custody (including voluntary attendance at a police station)
- The death has occurred whilst the patient is involuntarily detained under the provisions of the Mental Health Act
- The death is linked with abortion
- The death might have been contributed to by the actions of the deceased him/her self (e.g. drug abuse, solvent abuse, self-injury or overdose)
- The death might be due to industrial disease or related in any way to the deceased’s former employment, however long ago.
- The death occurred during or within 14 days after an operation or comparable clinical procedure. This includes deaths that might in any way be related to an anaesthetic. If the operation was performed for an injury of any kind, irrespective of how or when it occurred, the coroner should be informed since the death may be consequent upon and not merely subsequent to the accident.
- The death may be related to a clinical procedure or treatment
- The death might be due to lack of medical care
- The death might be related to a blood transfusion
- The death might be related to an adverse reaction to a drug or to poisoning of any kind
- The death occurs within 24 hours of admission to hospital, unless the admission is solely to provide terminal care
- The death is unusual or raises disturbing features
- It is usually prudent to report any death where there have been allegations of medical mismanagement or alleged negligence.
*Taken from Dorries, C P; Coroners’ Courts – a guide to law and practice; [2nd ed. 2004, OUP]Anyone who is concerned about the cause of a death can inform a coroner about it, but in most cases a death will be reported to the coroner by a doctor or the police.
What is a Coroner?
Coroners are Independent Judicial Officers responsible for investigating violent, unnatural, sudden deaths where the cause is unknown or where the person died while in custody or otherwise in state detention. They are appointed and paid by the relevant local authority. However, once appointed the Coroner is answerable only to the High Court for his/her judicial and administrative decisions. 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.
Any Coroner appointed after July 2013 has to be legally qualified. However, if the Coroner was appointed prior to this date they can be either a doctor or lawyer or both. The Coroner is responsible for investigating deaths in particular circumstances and can also arrange for a post-mortem examination of the body, if necessary. Each Coroner has a Deputy or Area Coroner and usually one or more Assistant Deputies. Either personally, or through a Deputy (or Area Coroner), the Coroner must be available at all times. The costs of the Coroners' service are met by the local authorities. The legislation governing Coroners is contained in the Coroners Act 1988 (as amended); The Coroners Rules 1984 (as amended); the Treasure Act 1996 and the Coroners and Justice Act 2009.
When a death is reported to a Coroner they:
- Make preliminary enquiries to decide if an investigation is necessary;
- If so, investigate to establish the identity of the person who has died; how, when and where they died but not why the person died; and any information required to register the death;
- May use information discovered during the investigation to assist in the prevention of other deaths;
- An investigation is to ascertain the facts concerning a death and does not apportion blame on any individual. The Coroner may decide to hold an Inquest as part of the investigation.
- A Coroner will hold an Inquest with a Jury in certain circumstances such as when someone dies in prison or police custody or other state detention such as an immigration detention centre.
What do Coroners do?
Coroners inquire into violent and unnatural deaths, sudden deaths of unknown cause, and deaths that have occurred in prison and certain other categories. A coroner's authority to inquire flows from the report of the fact that a body lies within the Coroner's Jurisdiction; it does not depend on where the death occurred. The Coroner's inquiries may take one of several forms and may result in the holding of an Inquest. It is a Coroner's duty at an Inquest to establish who the deceased was, how, when and where the deceased came by his or her death. After an Inquest the Coroner will send the necessary details to the Registrar of Births and Deaths so it can be registered when it occurred in England and Wales. An Inquest is not permitted to determine or appear to determine criminal liability by a named person or civil liability. It is about what happened, not who was responsible for what happened, for which the civil and criminal courts have jurisdiction. It is also about how someone died, not why he or she died. In some cases a death may be referred by the Coroner to the police for investigation on his behalf. In other cases a separate investigation into a death may be undertaken by an independent organisation such as the Health and Safety Executive, the Prisons and Probation Ombudsman, the Care Quality Commission, the Independent Office for Police Conduct, the Air Accidents or Marine Accident Investigation Branch, etc. The Coroner will be given the results of their investigation. Coroners also have jurisdiction over Treasure.
Are all deaths reported to a Coroner?
Not all deaths need to be reported. In many cases the deceased’s own doctor, or a hospital doctor who has been treating him or her during the final illness, is able to issue a Medical Certificate of the Cause of Death (MCCD) without reference to a Coroner. The death can then be registered by the Registrar of Births and Deaths, who will issue the death certificate. Sometimes doctors may discuss the case with the Coroner and this may result in the Coroner deciding that he/she does not need to make further inquiries because the death is from natural causes. In the light of that discussion the doctor concerned may be able to issue the MCCD and the Coroner will issue the appropriate paperwork to the Registrar stating that it is not necessary to hold an Inquest. However, if the Coroner decides to investigate a death, the Registrar of Births and Deaths must wait for the Coroner to finish his or her inquiries before the death can be registered. These inquiries may take time, so it is always best to contact the Coroner's office before any funeral arrangements are made. In many cases, the decision to investigate will not hold up funeral arrangements.
What happens after the Coroner is notified of a death?
The Coroner will usually deal with the case in one of three ways.
- He may make some telephone and/or other inquiries to satisfy him/herself that no inquest or post-mortem examination is necessary. If satisfied, he may issue a certificate that authorises the Registrar of Deaths to register the death and release of the body.
- If the cause of death is unknown (e.g. because a doctor cannot certify a cause) the Coroner may ask a pathologist to carry out a post-mortem examination (also known as an autopsy examination). If that reveals a natural cause of death and there is no reason to suspect that the death was violent or unnatural, the Coroner may decide not to hold an Inquest and will issue the appropriate paperwork. This allows the death to be registered and the body to be released.
- In all other circumstances, the Coroner will usually open an Inquest. It is usual for the body to be released promptly for burial or cremation, even if the Inquest cannot be held for some time, but there might be some delay in releasing the body if the death was 'suspicious'.
What happens if the coroner decides to hold an inquest?
A Coroner must hold an inquest if the cause of death remains unknown, if there is cause for the Coroner to suspect that the deceased died a violent or unnatural death or died in prison. If there has been an autopsy (post-mortem), the Coroner will normally issue the necessary authority permitting a burial or cremation, so that a funeral can be held, even though the inquest has not been concluded. In such circumstances, the death cannot be registered. In order to assist the administration of the estate, an interim certificate of fact of death can be issued by the Coroner. This certificate should be acceptable to banks and financial institutions, unless it is important for them to know the outcome of the inquest (for example, for an insurance settlement). This interim certificate can also be used for benefit claims and National Insurance purposes. After the inquest has been resumed and concluded, the Coroner will notify the Registrar of deaths by issuing an after-inquest certificate so that the death can be registered by the Registrar and a death certificate obtained.
Taking a body abroad or bringing it back to this country. In every case where someone wishes to take a body out of England or Wales (including cases of deaths from natural causes), written notice must be given to the Coroner in whose area the body is located. The Coroner will then consider whether an inquest or post-mortem examination is needed and will notify his/her decision within four days. If a body is being brought into England or Wales, the Coroner in the area to where the body is brought or is to be laid to rest may need to be involved. The Coroner may need to determine the cause of death and will be required to hold an inquest if the death was unnatural, violent, or sudden and of unknown cause. The Coroner will issue a Certificate for Cremation in all cases coming from abroad (including cases of deaths from natural causes) where the body is to be cremated. When death has occurred outside England and Wales and the body is returned to England or Wales, the death is not registered by the Registrar of Births and Deaths when the Coroner has finished investigating or has concluded the inquest. Further information about what to do when a death occurs abroad can be found on the Foreign and Commonwealth Office's website, at: www.fco.gov.uk/en/travel-and-living-abroad/when-things-go-wrong/death-abroad
What is a post-mortem examination?
A post-mortem examination is a medical examination of a body after death, carried out by a pathologist for a Coroner. Most examinations performed in England and Wales are post-mortems (also called autopsies and sometimes called necropsies) conducted by a pathologist of the Coroner's choice. The purpose is to establish the medical cause of death. In cases of suspected crime (such as murder or manslaughter), the examination will usually be conducted by a specialist forensic pathologist on the “Home Office List”.
Medical records remain confidential after death but may be made available to the deceased's personal representatives or a person who may have a claim arising out of the deceased's death. There are some statutory restrictions. Coroners are entitled to obtain copies of medical information that is relevant and necessary to their inquiries. Medical information about the deceased may be disclosed at the inquest hearing if it is relevant to the cause of death.
Post-mortem examination report
The post-mortem examination or autopsy report gives details of the examination that was made of the body and it is sent to the Coroner by the person who carried out the post-mortem examination. It may also give details of any tests (e.g. histology or toxicology) that have been carried out to help determine the cause of death. Copies of the report are normally available only to properly interested persons. A fee for the copies may be payable. A Coroner may dispense with an inquest after a post-mortem examination if he/she thinks an inquest is unnecessary and there is no reason to suspect that the person died a violent or unnatural death and they did not die in prison. The Coroner will release the body for the funeral and issue the appropriate paperwork to the Registrar of Births and Deaths stating the cause of death as disclosed by the post-mortem examination report. The death can then be registered. Generally, this will happen when the autopsy establishes that the person died of natural causes and the Coroner decides no further investigation into the death is necessary.
Will tissue or organs be retained after a coroner's post-mortem examination?
Pathologists cannot always determine a cause of death by macroscopic ("naked eye") examination at autopsy. They may need to perform further tests to ascertain the cause of death. This may involve taking small pieces of tissue to examine under the microscope, or it may involve taking blood or other body fluids for toxicological purposes. Sometimes it may be necessary to take whole organs for further examination e.g. the heart may need to be examined by a specialist cardiac pathologist in cases where apparently healthy young individuals die suddenly and unexpectedly. Pathologists may only take material that has a bearing on the cause of death. There are now strict rules about taking any material from a body at autopsy. The pathologist must inform the Coroner that he has done so and the Coroner must then inform the relevant properly interested persons and offer these persons three options. One option is for the material to be disposed of when it has served its purpose; the second option is for it to be returned to the deceased's family or representative if so requested; the third option is that, with consent, the material may be retained for medical research or other purposes. In cases involving homicide, tissue or whole organs may have to be retained by the Crown. Other statutory provisions apply, such as the Police and Criminal Evidence Act (PACE) or directions of the trial Judge. Further general information on tissue retention and the legal requirements relating to consent can be obtained from the Human Tissue Authority on: 020 7211 3400 or online at www.hta.gov.uk
Can there be a second autopsy?
If after the autopsy concerns remain about the cause of death, the relatives and others may ask the Coroner for a further post-mortem examination. Any such examination would be at their own expense. In cases where someone has died of criminal activity (homicide, assault, etc.) and a suspect has been apprehended who may be charged with a serious criminal offence, that person or his/her legal representative may request a further autopsy. If no one has been apprehended, the Coroner may arrange a second autopsy.
Is consent necessary? Who may attend the autopsy?
The Coroner is not required to obtain the consent of relatives or others for a post-mortem examination to be made. The Coroner will inform certain "properly interested persons" of when and where the autopsy will take place if those persons have notified the Coroner of their desire to attend the autopsy, unless it is impractical to notify them or to do so would cause the examination to be unduly delayed. The people entitled to notify the Coroner of their desire to attend include the deceased's relatives and others with an interest in the death, for example, the deceased's regular medical practitioner. Such persons are not entitled personally to be present, but are entitled to be represented at the examination by a doctor of their choice, but they have to pay any fee the doctor may charge. The Chief Officer of Police may notify a Coroner of his wish to be represented at a post-mortem examination and is then entitled to be represented by a Police Officer.
Is there an alternative to an autopsy?
England and Wales has one of the highest autopsy rates in the world. Many people dislike autopsies for religious, cultural and other reasons. Alternative methods of examination of bodies after death, such as Magnetic Resonance Imaging (MRI) and computed tomography (CT) scans, are undergoing research but have not yet been confirmed scientifically as acceptable alternatives to conventional autopsy in establishing medical causes of death. If diagnostic imaging techniques are scientifically validated, they are likely only to be available to those who are prepared to pay privately. Imaging techniques may prove to be a valuable adjunct to conventional autopsy even if they will not replace conventional autopsy. Coroners’ will, where possible, take account of religious and cultural needs. However, if a medical practitioner cannot provide a medical certificate of cause of death, the law is such that the Coroner may have little or no alternative but to arrange an autopsy.
When is there a duty to hold an inquest?
Where a Coroner is informed that the body of a person is lying within his Jurisdiction and there is reasonable cause to suspect that the deceased: - has died a violent or unnatural death; or - has died a sudden death of which the cause is unknown; or - has died in prison (or certain other places or circumstances) then, whether the cause of death arose within his Jurisdiction or not, the Coroner shall, as soon as practicable, hold an inquest into the death of the deceased.
What is an inquest?
An inquest is a fact-finding inquiry to establish who has died, how, when and where the death occurred. It is not a trial - no one is on trial in a Coroner's Court. Unlike other Courts, whether civil or criminal, there is no prosecution or defence. The Coroner's jurisdiction is inquisitorial rather than adversarial or accusatorial. The Coroner and others who are "properly interested persons" simply seek the answers to the above questions. An inquest is usually opened soon after a death to record that a death has occurred, to identify the deceased, and to enable the Coroner to issue the authority for the burial or cremation to take place without unnecessary delay. It will then be adjourned until other investigations and inquiries instigated by the Coroner have been completed. It usually takes between 3 and 9 months to conclude this work, but some cases can take longer than this if the inquiries prove to be complicated. Once all the investigations are complete, the inquest will be resumed and concluded.
What happens if somebody has been charged with causing the death?
Where a person has been sent for trial for causing a death, for example by murder, manslaughter, infanticide or certain types of road traffic deaths, the inquest is adjourned until the criminal trial is over. On adjourning an inquest, the Coroner sends the Registrar a certificate stating the particulars that are needed to register the death and for a death certificate to be issued. When the trial is over and the Coroner informed of the outcome, he/she will decide whether or not to resume the inquest. There may be no need if all the facts surrounding the death have emerged at the trial and, in such cases the Coroner will send another certificate to the Registrar of Deaths, confirming the outcome of the Crown Court trial. If the inquest is resumed the finding of the inquest as to the cause of death cannot be inconsistent with the outcome of the criminal trial.
What is the role of a coroner's officer?
Coroners' Officers come from a variety of professional backgrounds. They work under the direction of the Coroner and liaise with bereaved families, pathologists, the police, doctors, witnesses, funeral directors and many others. They receive reports of deaths and make inquiries at the direction, and on behalf, of a Coroner.
Attendance at an inquest
When a Coroner's investigations into a death are complete, a date for a full inquest will be set. The 'properly interested persons' (see below) will be informed of the date by the Coroner's Office and witnesses will be asked to attend to provide evidence. If they are unwilling to attend voluntarily they may be summoned. The inquest is held in the public interest and not on behalf of any individual. It is not always necessary for the bereaved relatives to attend the inquest and some prefer not to, as the details of the death may need to be dealt with in some detail. If you do attend the inquest a supporter, for example a friend, can accompany you. In many Coroners' Courts, volunteers from our Service (The Coroners Courts Support Service), may be there to offer support.
Evidence at inquest - oaths and affirmations; documentary evidence
At inquests, evidence has to be 'sworn' and therefore, the witness will be asked either to swear an oath on his or her relevant religious book or to affirm. The Coroner's Officer will ask the witness his or her preference. Some evidence at an inquest may be admitted in documentary form. This happens if the evidence is undisputed and no properly interested person wishes to question or challenge it. If the evidence is admitted in this way, the witness need not personally attend Court.
Will there be a jury at the inquest?
Most (about 99%) of inquests are held without a Jury but there are particular circumstances when a Jury must be called, including: - if the death occurred in prison or resulted from an injury caused by a police officer in the purported execution of his duty; or if the death resulted from an accident at work. In every Jury inquest, the Coroner decides matters of law and procedure and the Jury decides the facts of the case and reaches a conclusion. The Jury cannot blame someone for the death. If there is any blame, this can only be established by other legal proceedings in civil or criminal courts. However, the Jury can record facts that make it clear that the death was caused by a specific failure of some sort or by neglect.
Who decides which witnesses to call?
The Coroner decides who should be called to give evidence as a witness, and the order in which they give evidence, but the Coroner will listen to representations made to him by "properly interested persons" as to who should be called. Anyone who believes they may be of help or believes a particular witness should be called should inform the Coroner. The test is whether the witness is likely to provide evidence that is relevant to the matters that the Coroner has to investigate. The Coroner will decide whether the evidence is relevant to the investigation of the death.
Must a witness attend court? Witness summonses and contempt of court
If a witness lives in England and Wales and has evidence that the Coroner regards as relevant and important to help in establishing the facts of the death, he/she can be required to attend Court. A witness will usually be asked to attend the inquest voluntarily, but if they do not agree and their evidence is crucial, the Coroner may issue a witness summons to compel their attendance. If the witness then does not attend he/she may be arrested, brought before the Coroner and charged with contempt of Court. This is an offence that is punishable with a fine or a term of imprisonment. If a witness lives abroad they can be invited, but cannot be compelled to attend or to give evidence.
I can’t remember what I put in my statement, can I read it again
Yes, please ask the Coroner’s Officer for a copy of your witness statement.
English is not my first language and I am concerned I will not understand the proceedings, will there be an interpreter?
If you are a witness or the next of kin please speak to the Coroner’s Officer before the Inquest date and they may be able to organise an interpreter for you.
What do I call the Coroner?
You call the Coroner either Sir, Ma’am or Madam.
Who can ask witnesses questions?
Witnesses will be first questioned by the Coroner and then by any properly interested person or their legal representative. Whether a question is relevant to the purpose of the inquest is something the Coroner decides. Where relevant, the Coroner will warn a witness that he or she is not obliged to answer any question which might incriminate him/herself.
Who is a properly interested person?
The categories of properly interested persons are set out in the relevant legislation. They include: - a parent, spouse, child, civil partner or partner and any personal representative of the deceased; - any beneficiary of a life insurance policy on the deceased; - any insurer having issued such a policy; - a representative from a Trade Union to whom the deceased belonged at the time of death (if the death arose in connection with the person's employment or was due to industrial disease); - anyone whose action or failure to act may, in the Coroner's view, have contributed to the death;- the Chief Officer of Police (who may only ask witnesses questions through a lawyer);- any person appointed as an inspector or a representative of an enforcing authority or a person appointed by a Government Department to attend the inquest; or - anyone else who the Coroner may decide also has a proper interest. The Coroner decides who will be given properly interested person status.
I know as a properly interested person I can ask questions but can someone ask them on my behalf?
Please speak to the Coroner’s Officer about this before the date of the Inquest as it is the decision of the Coroner.
Rights of properly interested persons, including bereaved people
Properly interested persons involved in an inquest have certain rights; for example: - to be told the date, time and place of the inquest if one is needed and to question witnesses at the inquest, either in person or by a legally qualified representative. Bereaved people may also ask the Coroner, via the funeral director, for reasonable access to see the body before it is released for the funeral; and ask the Coroner for a copy of the post-mortem examination report (for which a fee may be payable), or to arrange for it to be seen free of charge; and ask the Coroner about a separate post-mortem examination. The costs of this examination, including any fee of the registered medical practitioner and mortuary charges, would have to be self-funded.
All the details that are completed on the Inquisition by the Coroner (or by the Jury) at the end of the inquest are "the conclusion". However, the short-form conclusion reached by the Coroner (or Jury) is commonly referred to as 'the conclusion. Commonly-used short form conclusions include: natural cause(s) - accident or misadventure; he/she killed him/herself (i.e. suicide); unlawful killing; lawful killing; industrial (or occupational) disease or open conclusion (where there is insufficient evidence for any other conclusion). The Coroner is not obliged to make use of a short form conclusion. He/she may use a variant or the Coroner may give a "narrative conclusion" which sets out the facts surrounding the death in narrative form.
What if future deaths may be prevented?
Sometimes the evidence at an inquest will show that something could be done to prevent similar fatalities. If so, at the end of the inquest the Coroner may announce that he/she will draw this to the attention of any person or organisation that may have the power to take action. This is something referred to as a "Regulation 28 Report" Anyone who receives such a report must send the Coroner a written response. These reports and the responses to them, are copied to all interested persons and to the Lord Chancellor. A summary of the reports is published twice a year by the Ministry of Justice.
What can you do if you are dissatisfied with the outcome of an inquest?
There are two methods by which a Coroner's decision can be challenged but the grounds for doing so are complex and advice should be sought from a lawyer with expertise in this area of the law. One method is an application to the High Court for judicial review of a decision, but this must normally be done within three months of completion of the inquest. There is also a separate power by which the Attorney-General may initiate an application to the High Court for an inquest to be held if a Coroner has neglected or refused to hold one, or for another inquest to be held on the grounds that it is necessary or desirable (e.g. because new evidence has come to light). Once a Coroner has reached a conclusion at the end of an inquest, he is functus officio - i.e. he ceases to have any further jurisdiction in the case and so cannot re-open it or re-hear it or amend his conclusions. Anyone wishing to challenge the conclusion must do so by one or other of the above methods.
Is it possible to obtain a record of the inquest?
Once an inquest has been completed, a properly interested person may apply to inspect (without charge) the notes of evidence or any document put in evidence at the inquest, or a copy of any post-mortem examination report. Copies may be obtained following payment of a fee to the Coroner. The notes may be in the form of a transcript from a voice recording or the Coroner's own notes. The Coroner's manuscript notes may not be a full verbatim record.
For more detailed information on disclosure please click here
Will the inquest be reported by the press and media?
Inquests must be held in public in accordance with the principle of open justice, so members of the public and journalists have the right to, and indeed may, attend the inquest and press reports may appear. The only exception is that parts of a very small number of inquests may be held in private for national security reasons. Whether journalists attend a particular inquest and whether they report on it is a matter for them. The Coroner cannot forbid them from attending Court. Press and media reports that are fair and accurate are unlikely to be actionable for defamation. Those working on newspapers or magazines must abide by the Editor's Code of Practice, upheld by the Press Complaints Commission, which sets out the guidance for print journalists in the UK. The Code, a copy of which is posted on the notice board outside the Coroner's Court and which can be seen at www.pcc.org.uk has requirements on accuracy, privacy and discrimination. It also has specific rules in cases involving grief and shock. For instance, publication in such circumstances must be handled sensitively and, when reporting suicide, care should be taken to avoid excessive detail about the method used. The Press Complaints Commission (PCC) mostly deals with complaints about published material. However, it can also help to prevent physical harassment by journalists and will sometimes be able to assist with problems related to material that has not yet appeared in print. Its staff are always happy to discuss matters informally; the PCC can be contacted on: 020 7831 0022 or 0845 600 2757. It also operates an out-of-hours number for emergencies only (07659 152656). The content of suicide notes and personal letters will not usually be read out at the inquest, unless the Coroner decides it is important to do so. If they are read out, their contents may be reported. Although every attempt is made to avoid any upset to people's private lives, sometimes it is unavoidable. Photographs taken of the deceased and of the scene of death may also form part of the evidence presented in Court, but the Coroner will always try to handle such material with sensitivity.
Is Legal Aid available?
Legal Aid is not generally available for representation at inquests because an inquest is a fact-finding process. Unlike other proceedings for which Legal Aid might be available, there are no parties in inquests, only properly interested persons. Witnesses are not expected to present legal arguments. The Coroner must ensure that the process is fair, impartial and thorough, and he or she should ensure that the relevant questions of properly interested persons are answered. Legal Aid may be available to cover representation at the inquest in exceptional cases. Applicants must qualify financially and meet strict criteria for representation to be funded. These criteria are that: there is a significant wider public interest in the applicant being represented at the inquest; or the circumstances of the death appear to be such that funded representation is likely to be necessary to enable the Coroner to investigate the case effectively and establish the facts, providing that the applicant was a member of the deceased's immediate family (as required by Article 2 of the European Convention on Human Rights). Legal advice - via the Legal Help scheme - may be available to those who qualify financially. Further information is available from the Legal Service Commission on: 0845 345 4345 or online at: www.legalservices.gov.uk
What about other legal proceedings?
Civil proceedings will normally follow (rather than precede) the inquest. When all the facts about the cause of death are known, it is possible that civil proceedings may be brought and a claim for damages made. A lawyer's advice should be sought about the time limits and procedures that apply. Inquest evidence cannot be used directly in other proceedings. Where criminal proceedings are to take place, they will sometimes take place before the inquest and sometimes after it depending on the type of case. The Coroner and his Officers will be pleased to advise on the matter.
Archive requests; finding out about long-dead relatives
There is much interest in tracing what happened to relatives but, by law, Coroners' files only have to be kept for 15 years (after this time only a 10% sample of files is kept). In some circumstances the Chief Coroner will direct Coroners to retain material for longer. After the 15 year period has expired, some material may be kept on a discretionary basis by the Coroner and Local Authority and some may be transferred to the National Archives. Queries about historic records should be directed to the Coroner's Office where the inquest was conducted. An archive search can be arranged at the discretion of the Coroner, and incurs a fee whether the search is successful or not.
Unless the death took place more than 75 years previously, the record may not be suitable for release. This is always at the discretion of the Coroner and would only be considered for those who could claim a proper interest. The boundaries of Coroners' Jurisdictions have altered over recent decades, making for problems in establishing the probable venue where any remaining records are held.
Local newspapers can be another source of information. The local archivist may be able so assist in tracing old news reports. Some newspapers are held in local libraries and in the British Library newspaper collection.
Treasure is now governed by the Treasure Act 1996. All finders of gold and silver objects and groups of coins from the same finds over 300 years old, have a legal obligation to report such items. Now prehistoric base-metal assemblages found after 1st January 2003 also qualify as Treasure. Advice on reporting a find may be found on https://www.finds.org.uk/treasure and a form downloaded from https://www.finds.org.uk/documents/treasurefinders.pdf The Coroner then has a duty to inquire and to determine whether or not the find is indeed treasure. No further advice on treasure will be found on this website, but anyone who requires more information should contact the relevant Coroner's Office or his/her local museum or the British Museum.
More information, including details of the 'Guide to Coroners', can be found elsewhere on this website or from the Coroner's Officers. Please see the links on this website; clicking on the links should take you to other sources of information. A further source of general information is the pre-recorded Metropolitan Police Bereavement Information Line on: 0800 032 9996. This is available to listen to 24 hours a day. Job Centre Plus publish a booklet “What to do after someone dies (DWP 1027)” which covers legal and benefits procedures. Registrars of Births and Deaths will give a copy to people who register a death and Coroners may make copies available to bereaved families. The booklet can be viewed online at:www.dwp.gov.uk/publications/catalogue-of-information/all-products. Further information about Coroners, death registration and related matters are available online at www.direct.gov.uk