To support practically and emotionally the family and other witnesses attending the Coroner’s Courts.
Registered Charity Number: 1105899 +44 (0)300 111 2141 info@ccsupport.org.uk

Information & Support

To support practically and emotionally the family and other witnesses attending the Coroner’s Courts.

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 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.

We can also signpost people to other organisations that may be able to help in the longer term.

Your experience

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.

  • 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.

The Inquest

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 they can provide.

There 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.”

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Coroners’ Courts across the UK

The map below shows all the coroners’ courts across the UK

Avon

The Coroner’s Office
The Courthouse, Old Weston Street
Flax Bourton
North Somerset
BS48 1UL
T: 01275 461920
Website

Bedfordshire and Luton

The Coroner’s Office
The Court House
Woburn Street
Ampthill
Bedfordshire
MK45 2HX
T: 0300 300 8383
Website

Berkshire

The Coroners Office
Yeomanry House
131Castle hill
Reading
Berkshire
RG1 7TA
T: 0118 937 2300
Website

Birmingham and Solihull

Coroner’s Court,
50 Newton Street,
Birmingham, B4 6NE
T: 0121 303 3920
Website

Black Country

Coroner’s Office
Smethwick Council House
High Street
West Midlands
B66 3NT
T: 0121 569 7200
Website

Blackburn, Hyndburn and Ribble Valley

The Coroners Office
Blackburn Enterprise Centre
Furthergate
Blackburn
BB1 3HQ
T: 01254 505000
Website

Blackpool and Fylde

Blackpool and Fylde Coroner’s Office
Municipal Buildings
Corporation Street
Blackpool
FY1 1GB
T: 01253 477128
Website

Brighton and Hove

The Coroner’s Office
Woodvale,
Lewes Road, Brighton,
East Sussex, BN2 3QB
T: 01273 292046
Website

Buckinghamshire

Coroner’s Office
29 Windsor End
Beaconsfield (Old Town)
HP9 2JJ
T: 01494 475205
Website

Cambridgeshire & Peterborough

Senior Coroner’s Office (Peterborough)
33 Thorpe Road
Peterborough
PE3 6AB
T: 0345 0451364
Website

Carmarthenshire and Pembrokeshire / Sir Gaerfyrddin a Sir Benfro

Coroner’s Office,
Town Hall,
Hamilton Terrace,
Milford Haven,
Pembrokeshire, SA73 3JW
T: 01646 698129
Website

Central and South East Kent

Elphicks Farmhouse,
Hunton
Maidstone,
Kent ME15 0SB
T: 03000 41 05 02

Central Hampshire

Coroner’s Office
New King’s Court
Tollgate,
Chandlers Ford
Eastleigh, SO53 3LG

Central Lincolnshire

Coroners Office
4 Lindum road
10 Queen Street
splisby
Lincolnshire
PE23 5JE
T: 01522 555778
Website

Ceredigion

Brunton & Co.,
6 Upper Portland Street,
Aberystwyth,
Ceredigion SY23 2DU
T: 01970 612567

Cheshire

The Coroner’s Office
The Town Hall
Warrington
WA1 1UH
T: 01925 444216
Website

City of London

City Coroner’s Office,
Walbrook Wharf
78-83 Upper Thames Street,
London EC4R 3TD
T: 020 7332 1598
Website

 

Cornwall

The Coroner’s Office
14 Barrack Lane,
Truro, TR1 2DW
T: 01872 324438
Website

County Durham and Darlington

HM Coroner’s Office,
PO Box 282,
Bishop Auckland
DL14 4FY
T: 03000 265556
Website

Coventry

Coroner’s Office
OCU Headquarters
Little Park Street
Coventry, CV1 2JX
T: 024 7683 3345
Website

Cumbria

The Coroner’s Office
Fairfield,
Station Road,
Cockermouth CA13 9PT
T: 01900 706902
Website

Derby and Derbyshire

St. Katherine’s House,
St. Mary’s Wharf, Mansfield Rd,
Derby, DE1 3TQ
T: 01332 343225
Website

Dorset

The Coroner’s Court,
Stafford Road,
Bournemouth, BH1 1PA
T: 01202 454910
Website

East Lancashire

East Lancashire Coroner’s Office
Lyndhurst House
Todmorden Road
Burnley BB10 4AB
T: 0300 123 6705
Website

 

East London

Coroner’s Court,
Queen’s Road,
London, E17 8QP
T: 020 8496 5000
Website

East Riding and Hull

The Coroner’s Office and Court,
The Guildhall
Alfred Gelder Street
Hull , HU1 2AA
T: 01482 613009

East Sussex

28/29 Grand Parade,
St Leonard’s on Sea
East Sussex, TN37 6DR
T: 01424 723030
Website

Essex

Essex County Council
A Block Ground Floor
County Hall
Victoria Road South
Chelmsford,
Essex CM1 1QH
T: 0333 0135 000
Website

Exeter and Greater Devon

Coroners Office
Room 226
Devon County Court
Topsham Road
Exeter
EX2 4QL
T: 01392 383636
Website

Gateshead and South Tyneside

Coroner’s Office,
35 Station Road,
Hebburn,
Tyne and Wear NE31 1LA
T: 0191 483 8771
Website

Gloucestershire

Coroners Court
Corinium Avenue
Barnwood
Gloucester GL4 3DJ
T: 01452 305661
Website

Gwent

Victoria Chambers,
11 Clytha Park Road,
Newport NP20 4PB
T: 01633 264194

Hartlepool

Offices of DMA
Coroners Dept.
155 York Road,
Hartlepool,
TS26 9EQ
T: 01429 274732
Website

Herefordshire

Town Hall
St Owen Street
Hereford
HR1 2PJ
T: 01432 260565
Website

Hertfordshire

Coroner’s Office,
The Old Courthouse
St. Albans Road East,
Hatfield,
Herts. AL10 OES
T: 01707 292707
Website

Inner North London (Camley Street)

St Pancras Coroner’s Court,
Camley Street,
London,
N1C4PP
T: 020 7974 4545
Website

Inner North London (Poplar High Street)

Poplar Coroner’s Court
127 Poplar High Street
London
E14 0AE
T: 020 7974 4545
Website

Inner South London

Coroner’s Court,
1 Tennis Street,
London, SE1 1YD
T: 020 7525 4200
Website

Inner West London

Westminster Coroner’s Court,
65 Horseferry Road,
London, SW1P 2ED
T: 020 7641 1212
Website

Isle of Scilly

Coroner’s Torbay office
Carey Chambers
1 Park Steet
Torquay
TQ2 5EL
T: 01803 380705
Website

Isles of Wight

The Coroner’s Office,
3-9 Quay Street,
Newport,
Isle of Wight, PO30 5BB
T: 01983 535100
Website

Leicester City and South Leicestershire

Coroner’s Office
2nd Floor, Town Hall,
Town Hall Square,
Leicester, LE1 9BG
T: 0116 225 2534
Website

Liverpool and Wirral

HM Coroner’s Court,
Gerard Majella Courthouse,
Boundary Street,
Kirkdale,
Liverpool, L5 2QD
T: 0151 233 5770
Website

Manchester (City)

HM Coroner’s Office & Court
PO BOX 532
Manchester Town hall
Albert Square
Manchester
M60 2LA
T: 0161 219 2222
Website

Manchester North

Coroner’s Office,
Phoenix Centre
Church street
Heywood
OL10 1LR
T: 01706 924815
Website

Manchester South

Coroner’s Court,1,
Mount Tabor Street,
Stockport
SK1 3AG
T: 0161 474 3993
Website

Manchester West

HM Coroner’s Court
Paderborn House,
Howell Croft North,
Bolton, BL1 1QY
T: 01204 338799
Website

Mid Kent and Medway

Coroner’s Office,
Kent Register Office
The Archbishop’s Palace
Mill Street
Maidstone
Kent ME15 6YE
T: 03000 41 05 02
Website

Milton Keynes

Coroner’s Office,
Civic Offices
1 Saxon Gate East
Central Milton keynes
Bucks
MK9 3EJ
T: 01908 691691
Website

Newcastle-upon-Tyne

Coroner’s Office,
Newcastle Civic Centre,
Barras Bridge
Newcastle upon Tyne NE1 8QA
T: 0191 277 7280
Website

Norfolk

Coroner’s Office
69-75 Thorpe Road
Norwich
NR1 1UA
T: 01603 276493
Website

Northamptonshire

Coroner’s Office,
110 Whitworth Road
Northampton
NN1 4HJ
T: 03000 111222
Website

North East Hampshire

Coroner’s Office
London Road
Basingstoke
Hampshire RG21 4AN
T: 01256 478119
Website

North East Kent

Coroner’s Office,
5 Lloyd Road,
Broadstairs,
Kent, CT10 1HX

North Lincolnshire and Grimsby

Coroners Office
Cleethorpes Town hall
Knoll Street
Cleethorpes
Lincolnshire
DN35 8LN
T: 01472 324005
Website

North London

Coroner’s Court,
29 Wood Street
Barnet EN5 4BE
T: 020 8447 7680
Website

North Northumberland

Coroners office
17 Church Street,
Berwick-upon-Tweed,
TD15 1EE
T: 01289 304318

North Tyneside

Coroner’s Office,
3 Stanley Street, Blyth,
Northumberland
NE24 2BS
T: 01670 354777

North Wales (East and Central)/ Gogledd Cymru (Dwyrain a Chanol)

Coroner’s Office
County Hall
Wynnstay Road
Ruthin
Denbighshire
LL15 1YN
T: 01824 708047
Website

North West Kent

Coroner’s Office,
The White House,
Melliker Lane,
Hook Green,
Meopham,
Kent DA13 0JB
T: 01474 815747

North West Wales / Gogledd Orllewin Cymru

Coroner’s Office
Maes Glas 37 Y Maes,
Castle square
Caernarfon,
Gwynedd LL55 2NN
T: 01286 672804

North Yorkshire (Eastern)

Forsyth House
Market Place
Malton
North Yorkshire
YO17 7LR
T: 01653 600070
Website

North Yorkshire (Western)

HM Coroner
21 Grammar School Lane
Northallerton,
North Yorkshire
DL6 1DF
T: 01609 533 843
Website

Nottinghamshire and Nottingham

Coroners Office,
Office and Main Court,
The Council House,
Old Market Square,
Nottingham NG1 2DT
T: 0115 841 5553
Website

Oxfordshire

Oxfordshire Coroner’s Service,
Oxford Registration Office,
Second Floor, 1 Tidmarsh Lane,
Oxford, OX1 1NS
T: 0845 605 4174
Website

Plymouth Torbay and South Devon

Coroner’s Torbay office
Carey Chambers
1 Park Steet
Torquay
TQ2 5EL
T: 01392 383636
Website

Portsmouth and South East Hampshire

Coroner’s Office
The Guildhall
Guildhall Square
Portsmouth P01 2AB
T: 023 9268 8326
Website

Preston and West Lancashire

Coroner’s Court,
2 Faraday Court
Faraday Drive,
Fulwood, Preston PR2 9NB
T: 01772 703700
Website

Rutland and North Leicestershire

Coroner’s Office
Southfield Road
Loughborough
Leicestershire
LE11 2TR
T: 0116 305 7732
Website

Sefton, St Helens and Knowsley

Coroner’s Office,
Southport Town Hall
Lord Street,
Southport, PR8 1DA

Shropshire, Telford and Wrekin

HM Coroner’s Service
3rd Floor
The Guildhall
Frankwell Quay
Shrewsbury SY3 8HQ

Somerset (Eastern)

Coroners
Faulkners Solicitors,
22 Bath Street,
Frome,
Somerset, BA11 1DL

Somerset (Western)

Coroner’s Office,
Blackbrook Gate,
Blackbrook Park Avenue,
Taunton,
Somerset, TA1 2PG

South Lincolnshire

Office of HM Coroner
Unit 1, Gilbert Drive Endeavour Business Park
Wyberton Fen
Boston, Lincolnshire PE21 7TQ

South London

Coroner’s Office
St Blaise Buildings,
Bromley Civic Centre,
Stockwell Close,
Bromley BRI 3UH

South Northumberland

Coroner’s Office,
3 Stanley Street,
Blyth,
Northumberland NE24 2BS

South Staffordshire

Coroner’s Office,
No 1 Staffordshire Place
Stafford ST16 2LP

South Wales and Central

The Coroners Office
1st Floor Rock Grounds
Aberdare
CF44 7AE

South Yorkshire (East)

Coroner’s Office,
The Crown Court College Road
Doncaster
DN1 3HS

South Yorkshire (West)

Coroner’s Office,
Medico-Legal Centre,
Watery Street,
Sheffield, S3 7ES

Southampton and New Forest

Coroner’s Court,
12-18 Hulse Rd
Southampton
S015 2JX

Stoke on Trent and North Staffordshire

Coroner’s Chambers,
547 Hartshill Road,
Stoke-on-Trent, ST4 6HF

Suffolk

Coroner’s office
Floor 3
Landmark House
Egerton Rd
Ipswich,
Suffolk IP1 5PE

Sunderland

Office of HM Coroner
Civic Centre, Burdon Road
Sunderland, SR2 7DN

Surrey

HM Coroner’s Court
Station Approach
Woking
Surrey GU22 7AP

Swansea and Neath Port Talbot/ Abertawe a Chastellnedd Port Talbot

Coroner’s Office
Civic Centre
Oystermouth Road
Swansea, SA1 3SN

Teesside

Coroner’s Office,
Register Office,
Corporation Road,
Middlesbrough
TS1 2DA

Warwickshire

Warwickshire Justice Centre
Newbold Terrace
Leamington Spa
CV32 4EL

West London

Coroner’s Court,
25 Bagleys Lane,
London, SW6 2QA

West Sussex

Coroner’s Office,
3 Orchard Street
Chichester
West Sussex PO19 1DD

West Yorkshire (Eastern) - Northgate

Coroner’s Office,
71 Northgate,
Wakefield, WF1 3BS

West Yorkshire (Eastern) - Belgrave Street

Coroner’s Office,
Symons House
Belgrave Street
Leeds, LS2 8DD

West Yorkshire (Western)

Coroner’s Office,
City Courts,
The Tyrls,
Bradford, BD1 1LA

Wiltshire and Swindon

Coroners Office
26 Endless Street
Salisbury, SP1 1DP

Worcestershire

The Court House,
Bewdley Road,
Stourport on Severn,
Worcs. DY13 8XE

York

Coroner’s Office,
Sentinel House,
Peasholme Green,
York, YO1 7PP

Information & Support

The Coroner's Court - Who will be there and what they do.

Hover over to find out Family Others Witnesses Coroner’s Office Coroner Coroner’s Clerk Coroner’s Support Volunteer
The Family:

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 at court:

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.

Witnesses:

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.

The Coroner:

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

Coroners' Office:

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 Coroner's Clerk:

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).

Coroner Volunteers:

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.

Bereavement Support

Content coming soon…

Information on the 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. 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.

When a death is reported to a Coroner they:

  • Make preliminary inquiries 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 happens once a death is reported to the coroner

The coroner may be the only person able to certify the cause of death. The doctor will write on the Formal Notice that the death has been referred to the coroner. The Formal Notice is issued to you by the attending doctor and is a document that explains how you register the death.
The coroner will then decide whether there should be further investigations into the death – and the registrar cannot register the death until notified of the coroner’s decision. This means that the funeral will usually also be delayed. Where a post-mortem has taken place, the coroner must give permission for cremation.

In some cases the Coroner will review the available reports and be satisfied that the person died of natural causes.  There is therefore no need to inquire any further and permission will be given to the GP or hospital doctor to issue the Medical Certificate of Cause of Death (MCCD).   Relatives can then register the death at the Register Office just as they would have had the MCCD been issued without referral to the Coroner.  Once this has been done the funeral can take place.

Which deaths are reported to the coroner

Approximately half of all deaths in England and Wales are referred to HM Coroner.  A death should be referred if;

  • the cause of death is unknown;
  • it cannot readily be certified as being due to natural causes;
  • the deceased was not attended by a doctor during the last 14 days or viewed after death;
  • there are any suspicious circumstances or history of violence;
  • the death may be linked to an accident (wherever it occurred);
  • there is any question of self-neglect or neglect by others which may have caused or contributed to the death;
  • the death occurred abroad (including Scotland and Northern Ireland)
  • a Public Authority has been involved in the care of the deceased, particularly if:
  • the death has occurred or the illness arose during or shortly after detention in police or prison
  • custody (including voluntary attendance at a police station and remand to a Bail Hostel)
  • the deceased was detained or was a voluntary patient under the Mental Health Act 1983
  • the deceased was subject to a Deprivation of Liberty Order (Mental Capacity Act 2005)
  • the death might have been contributed to by the actions of the deceased (such as a history of drug or solvent abuse, self-injury or overdose);
  • the death could be due to an occupational disease or related in any way to the deceased’s current or previous employment;
  • the death occurred during an operation or was in any way related to an anaesthetic (in any event a death within 24 hours of admission to hospital should normally be referred);
  • the death occurs within 1 year of surgery and the cause of death is implicated to the medical procedure/treatment (whether invasive or not);
  • there is an actual or potential expression of concern about a patient’s treatment, care or management;
  • the death occurs in the surgery of a GP the death is linked with child birth or an abortion (but not a stillborn child);
  • the death is of a child (under 18 years of age)
  • death of a Mother within 1 year of Child Birth (including stillbirth or spontaneous abortion);
  • there are any other unusual or disturbing features to the case.

The above list is not exhaustive.

Reports are made mainly by doctors and the Police.  Upon receipt of a death report the Coroner will review the information and decide what should be done.  Please see below for the various possibilities.

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, a registrar or the police.

Post-mortems

In some cases, the coroner will need to order a post-mortem. This is a medical examination of the body to find out more about the medical cause of death. In these cases, the body will be taken to a mortuary for this to be carried out.
A post-mortem examination will be necessary if;

  • The cause of death is not known.  Even if the cause is likely to be natural it is necessary to

find out which disease or condition was involved.

  • The cause of death may be unnatural.
  • The deceased died in some circumstances of state detention.

The Coroner never requests a post-mortem examination without careful consideration.  Where it seems likely that death was due to natural causes, they make every effort to trace a doctor who may be able to certify the cause of death.

What happens when the results come back?

When the post-mortem examination is completed, the Pathologist will report their findings to the Coroner and then one of three things will happen;

  • If the post-mortem examination confirmed that the deceased died of natural causes the

Coroner’s involvement will cease and paperwork will be issued to allow the death to be registered

  • If the cause of death could not be immediately identified and the pathologist is to

undertake further tests the Coroner will commence an Investigation which may or may not include an Inquest.  The pathologist’s report indicating the cause of death can take some time to compile but this should be received by the Coroner within 6 weeks. However, if there has been a specialist examination the results could take longer.  The next of kin should be kept informed.

  • If the post-mortem revealed an unnatural cause of death an Inquest will be opened and a

date for pre-Inquest review and/or final hearing will be set

You do not have the right to object to a post-mortem ordered by the coroner, but you should tell the coroner if you have religious or other strong objections. In cases where a death is reported to a coroner because the person had not seen a doctor in the previous 14 days (28 in Northern Ireland) the coroner will consult with the deceased person’s doctor and will usually not need to order a post-mortem.

Download a Guide to Coroner Services: booklet here

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/363879/guide-to-coroner-service.pdf

Download Coroner Investigations – a short guide: leaflet here

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/283937/coroner-investigations-a-short-guide.pdf

Information provided by DirectGov (Crown copyright)

Role of the Coroner’s Officer

Coroners’ officers work under the direction of coroners making enquiries into the circumstances of deaths that are sudden and of unknown cause; are due to unnatural causes or deaths that occur in custody. They liaise with bereaved families, the police, doctors, witnesses, mortuary staff, hospital bereavement staff and funeral directors. They receive reports of deaths and make inquiries at the direction, and on behalf, of a coroner.

Coroners Officers may be serving police officers, civilian police staff or they may be local authority employees.

Coroners officers are often the main point of contact for the coroner’s office and will liaise or speak to a number of people including the bereaved relatives and family representatives; doctors and other health professionals; police and other emergency services; registrars of births and deaths; funeral directors; pathologists and mortuary staff and any others who may be relevant depending on the case.

The coroners officer will take a report of a death, create a record and obtain all the relevant information so the coroner can make decisions on how to proceed with the case. For example, whether there must be an inquest or not and whether a post-mortem examination is necessary or not.

A large part of the role is discussing medical causes of death with doctors. Where necessary the coroners’ officer will arrange the post-mortem examinations, which are conducted by a pathologist. If an inquest is necessary a coroner’s officer will be responsible for ensuring that a thorough investigation is carried out and an inquest file produced. In some areas, the coroner’s officer will arrange and attend the inquest hearing. Much of the work is carried out on the telephone.

Gathering information and raising concerns

When a Coroner opens an inquest, they will instruct their Officers to put together a file of paper evidence.  Different types of evidence will be needed depending on the circumstances of the death.

The file often includes a statement from a member of the family about the deceased’s personal background and any information that is known about their health.  This is called the antecedent statement.  A Coroner’s Officer will take the statement from the family member either face-to-face or over the phone.  It is not always the next of kin that makes the statement.  The Officer will speak with whoever is best able to give the information and feels able to cope with doing so.

If family members have concerns about any of the circumstances of the deceased’s death, they can raise them when making the statement if they wish.  Alternately, they may prefer to write a separate letter to the Coroner once they have had a little longer to gather their thoughts.  The Coroner takes all concerns raised by relatives seriously and tries to ensure that their questions are answered.  The Coroner, by law, can only look into matters that relate to the four questions that an inquest covers (who has died, when, where and how they died).

As well as the personal background statement, the file will include the report of the post mortem examination, if one was carried out.  There may then be additional reports from doctors, nurses, Police Officers, eyewitnesses or any other people the Coroner feels appropriate.  Occasionally, the Coroner may commission an independent expert opinion report.  Every file is unique.

What information can I get before the hearing?

The inquest process should be open and transparent for families.  Once the inquest date, is set the Coroner’s Officer will prepare a file containing copies of all the reports and statements they have obtained and the next of kin is entitled to have copies of these reports. This is known as pre-inquest disclosure.

Please be aware that the reports, especially the post mortem examination report, contain detailed medical information and/or descriptions of injuries.  Photographs are not usually included of your relative or their place of death.

 

Attending an Inquest

An inquest is a legal inquiry into the medical cause and circumstances of a death. It is held in public – sometimes with a jury – by a coroner, in cases where the death was:

  • violent or unnatural
  • took place in prison or police custody
  • or when the cause of death is still uncertain after a post-mortem

Coroners hold inquests in these circumstances even if the death occurred abroad (and the body is returned to Britain). If a body is lost (usually at sea) a coroner can hold an inquest by order of the Secretary of State if death is likely to have occurred in or near a coroner’s area of jurisdiction.

If an inquest is held, the coroner must inform:

  • the married or civil partner of the deceased
  • the nearest relative (if different from the above)
  • and the personal representative (if different from the above)

Relatives can also attend an inquest and ask questions of witnesses – these questions can only be about the medical cause and circumstances of the death. Relatives can also ask a lawyer to represent them, but there is no legal aid available for this.

It may be particularly important to have a lawyer to represent you if the death was caused by a road accident, an accident at work, or other circumstances which could lead to a claim for compensation. You cannot get legal aid for this.

What role do relatives have?

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.

List of Courts covered by the CCSS

The Coroners’ Courts Support Service is a registered charity whose trained volunteers give emotional and practical support to families and other witnesses attending Inquests at the following Coroner’s Courts:

London:

Barnet in North London

Croydon in South London

Fulham in West London

St Pancras In Inner London North

Southwark in Inner London South

Walthamstow in East London

Westminster   in Inner London West

 

The rest of the country:

Ampthill in Bedfordshire

Beaconsfield in Buckinghamshire

Blackburn

Blackpool & Fylde

Bradford in West Yorkshire West

Cannock in South Staffordshire

Canterbury, Margate & Sandwich in North East Kent

Chelmsford in Essex

Cockermouth, Kendal, Carlisle and Barrow in Furness in Cumbria

Coventry

Crawley in West Sussex

Crook in the County of Durham & Darlington

Flax Bourton in Avon

Hatfield in Hertfordshire

Huntingdon and Chatteris in Cambridgeshire

Leicester in Leicestershire

Lincoln, Soilsby, Spalding & Stamford in Central & South-East Lincolnshire

Liverpool in Liverpool & the Wirrall

Maidstone in Mid Kent & Medway

Manchester City

Middlesbrough & Hartlepool in Teesside

Milton Keynes in Buckinghamshire

Newcastle upon Tyne

Northallerton & Scarborough, Harrogate, Selby, Skipton & York in North Yorkshire East & West

Oxford in Oxfordshire

Peterborough

Reading in Berkshire

Shrewsbury in Shropshire, Telford & Wrekin

Stockport in Greater Manchester

Stoke on Trent in North Staffordshire

Sunderland

Truro in Cornwall

Warrington, Crewe, Chester & Macclesfield in Cheshire

Woking in Surrey

How we spend your donations

It takes approximately four months to set up a service in a new location. This input of time requires a great amount of money and your generous donations are used in the following ways.

Training our volunteers

  • Formal interviews are conducted after receiving the completed application
  • Each potential volunteer has between 4-7 days of observing Inquests
  • Potential volunteers will then ‘shadow’ an experienced volunteer before being shadowed themselves by an experienced volunteer to gain confidence and an understanding of what the role entails
  • Potential volunteers undertake 3 further days of formal training
  • On successful completion of the formal training references and DBS checks are taken up
  • Volunteers are managed, supported and supervised by members of appropriately experienced staff
  • Volunteers attend team meetings and further training opportunities
  • Volunteers are also invited to attend the Regional Meetings

Staff Remuneration

  • Five members of staff recruit, manage, support and supervise all of the volunteers and attend local volunteer team meetings
  • The staff members also meet with the Coroners and Coroner’s Officers to gain feedback and to ensure an effective, high quality service is being provided
  • All training is developed and delivered in-house by the staff members
  • We produce policies and procedures which includes standards of service to ensure a professional service is being delivered

F.A.Q

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?

A Coroner is an independent judicial office-holder, 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. If appointed prior to July 2013 a Coroner may be an experienced lawyer or a doctor, and in some cases, they can be both. If the Coroner was appointed after July 2013 they must be an experienced lawyer. 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.

The Coroner’s Office
Most coroners have one or more Coroners Officers to help them carry out their duties. The usual contact between the public and the coroner will be through one of these Officers, who, on behalf of the Coroner, is responsible for investigating the death.

The Coroner is limited by law in what s/he may do. An inquest is a fact-finding inquiry. It is not a trial. The purpose of an inquest is as follows

An inquisition…
shall set out, so far as such particulars have been proved –
who the deceased was; and
how, when and where the deceased came by his death;

The proceedings and evidence at an inquest shall be directed solely to ascertaining the following, namely –
Who the deceased was;
How, when and where the deceased came by his death;
The particulars … required by the Registration Act to be registered concerning the death
Neither the coroner nor the jury shall express any opinion on any other matter”

No conclusion shall be framed in such a way as to appear to determine any question of –
criminal liability on the part of a named person
civil liability

 

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 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.

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.

  1. 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.
  2. 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.
  3. 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

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.

Inquest verdicts
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.
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. An archive search can be arranged at the discretion of the Coroner, and incurs a fee whether the search is successful or not. Local newspapers can be a source of information. The local archivist may be able to assist in tracing old news reports. Unless the death took place more than 75 years previously, the record may not be suitable for release, which 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 extant records are held.
Treasure
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 http://www.finds.org.uk/treasure and a form downloaded from http://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.
Further information
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

 


Ministry of Justice Website