It is the role of the Coroners Service to investigate and record the causes and circumstances of all sudden deaths where the cause is unknown. The information on this page aims to help make the Coroners Service as easily understandable and accessible as possible.
Questions
Here are the questions that we hope explains the service that the coroner’s service provides. Click on a question to see the answer.
A coroner is an independent office holder, who is either a lawyer or a doctor, and in some cases is both. Each coroner has a deputy and usually one or more assistant deputies, and between them they must be available at all times. Coroners are helped by their officers who work under the direction of the coroner.
It is the coroners’ duty to investigate sudden unexpected deaths where the cause is unknown or where the death occurs in legal custody. It is the coroner’s duty to establish who the deceased was and how, when and where the deceased came by his or her death. The coroner’s inquiries may result in the holding of an inquest. This inquest is to determine what happened, not who was responsible for what happened.
Coroners’ officers work under the direction of coroners and liaise with bereaved families, the police, doctors, witnesses and funeral directors. They receive reports of deaths and make inquiries at the direction, and on behalf of a coroner.
No, deaths are usually reported to the coroner by the police or by a doctor if the death is sudden or unexpected. In most cases the deceased’s own doctor, or a hospital doctor who has been treating him or her, is able to give a cause of death so 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 Registration Services who will issue the death certificate.
If the coroner has decided 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.
There are a number of occasions when a death will be reported to the coroner, by a doctor, the police or the registrar of births and deaths. This could include where it appears that:
- No doctor attended the deceased during his or her last illness;
- Although a doctor attended during the last illness the deceased was not seen either within 14 days before death nor after death;
- The cause of death appears to be unknown;
- The death occurred during an operation or before recovery from the effects of an anaesthetic;
- The death was due to an industrial accident, disease or poisoning;
- The death was sudden or unexpected;
- The death was unnatural;
- The death was due to violence or neglect;
- The death was in other suspicious circumstances; or
- The death occurred in prison or police custody.
The coroner has a duty to investigate and record the details of any sudden death where the cause is not known. The coroner may decide that a post-mortem examination and inquest are unnecessary because the cause of death is evident, and there is a doctor who can verify it. Alternatively the coroner may ask a pathologist to examine the body and carry out a post-mortem examination.
A post-mortem is a medical examination of a body, carried out for the coroner by a pathologist of the coroner’s choice, in order to establish the cause of death.
When the coroner decides that a post-mortem examination is necessary, wherever possible, the immediate next of kin, whose details are known, will be given an explanation why a post-mortem examination is necessary and what is involved, if requested; and when it is expected to take place so that they may be represented (by a doctor) if they wish. It is important to note that post-mortem examinations must be undertaken as soon as possible, and notice may not always be practicable.
The relatives can ask the coroner for a separate, additional post-mortem examination if they still have concerns about the cause of death. This would be at the expense of the family and not the coroner’s service.
A post-mortem examination report details the assessment made on the body and is sent to the coroner by the pathologist that carried out the examination. It may also give details of any further tests carried out to help determine the cause of death. Copies of the report are normally available to the next-of-kin. A fee may be payable for further copies.
No, a coroner may decide not to hold an inquest after a post-mortem examination as there is no reason to suspect that the person died a violent or unnatural death, and they did not die in prison. If this is the case then the body will be released for the funeral and a form will be sent to the registrar of births and deaths stating the cause of death so that the death can be registered.
Distressing though it can be for the deceased’s family, organs and tissue may sometimes be removed from a body and preserved by a pathologist if they have any bearing on the cause of death or the identity of the deceased.
If the deceased wished to be an organ donor than the next-of-kin would need to seek advice from the hospital or from the local Transplant Co-ordinator, who will be able to discuss the options for donation in more detail. The coroner will then be consulted for any case which has been or is likely to be referred to him or her, and the coroner must agree before a donation can take place. These decisions are usually made very quickly.
A coroner must hold an inquest if the cause of death remains unknown, or if there is cause for the coroner to suspect that the deceased died a violent or unnatural death, or died in prison. However, after the post-mortem examination is completed 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.
No, if there is an ongoing inquest then the death cannot be registered. An interim certificate of fact of death can be issued by the coroner to assist in the administration or the estate. It should be acceptable for banks and financial institutions unless it is important for them to know the outcome of the inquest. When the inquest has been completed, the coroner will notify the registrar so that the death can be registered by the registrar and a death certificate can be obtained.
In every case where someone wishes to take a body out of England or Wales, 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 or 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 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, or violent, or sudden and of unknown cause.
When death has occurred outside England and Wales and the body is returned here, the Death Certificate will have been issued in the country where the death occurred rather than by the Registrar here. When the body is returned to England or Wales, then the death is treated in exactly the same way as if the death had occurred here, rather than abroad, whereby the coroner will consider whether an inquest or post-mortem examination is needed.
An inquest is an inquiry into who has died and how, when and where the death occurred. It is not a trial as the coroner will not apportion blame.
An inquest is usually opened soon after a sudden, unexplained death has occurred. This is to identify the medical cause and circumstances of the death. This will then enable the coroner to issue the authority for the burial or cremation to take place without any unnecessary delay.
When the coroner's investigations are complete, a date for the resumed inquest is set and the interested parties will be notified of that date. All inquests are open to the public and journalists are usually present.
The inquest will be held at the Coroners Court in Loughborough or the Town Hall in Leicester City Centre. Information on the court facilities and how to get there is available on the Contact Information page.
Most inquests are held without a jury but there are particular circumstances when a jury is called. The inquest will be held with a jury if the death occurs in prison, in custody, at work or if further deaths may occur in similar circumstances. In these cases, the coroner decides matters of law and the jury decides the verdict.
You may wish to be legally represented at the inquest but it is not usually necessary because an inquest is an inquiry conducted by the coroner and is not a trial.
Legal aid is not normally available at an inquest as it is a fact-finding process where the coroner will ensure that the process is impartial and thorough.
The coroner decides who to ask and in what order they are to give evidence as a witness. Anyone who believes they can help, or believes a particular witness should be called, should inform the coroner.
A witness must attend court as their evidence as a witness may be vital in establishing the facts of the death. A witness may be asked to attend the inquest or receive a formal summons to do so.
Witnesses will be first questioned by the coroner and then by any properly interested person (see Q29) or their legal representative. The coroner decides whether a question is relevant to the inquest and where relevant, the coroner will warn a witness that he or she is not obliged to answer any question which might incriminate them.
A properly interested person has the right to participate in the inquest. This includes:
- 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 an person appointed by a Government Department to attend the inquest; or
- Anyone else who the coroner may decide also has a proper interest.
There are many possible outcomes of the inquest which include:
- Natural causes;
- Accident or misadventure;
- He or she killed him/herself (i.e. suicide);
- Unlawful killing;
- Lawful killing;
- Industrial disease; or
- Open verdict (where there is insufficient evidence for any other verdict).
It is possible to challenge the outcome of the inquest but the grounds for doing so are complicated and advice from a lawyer should be sought. An application may be made to the High Court for judicial review of a decision, but this must normally be done within three months of completion of the inquest.
Once an inquest has been completed, a properly interested person may apply to see the notes of evidence, 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.
All inquests must be held in public. Whether journalists attend a particular inquest, and whether they report on it, is a matter for them. The media are not entitled to any more information than that which is given in court.
If a person finds an object which they believe to be Treasure then they should report it to the coroner’s service within 14 days. Failure to do so is a criminal offence. For further information see the Treasure Content on the Inquest page.
The information provided here relates to the coroner’s service for the Rutland & North Leicestershire District. We hope that this information helps to answers any questions you may have regarding the coroner’s service.
If you are a ‘properly interested person’, in a specific inquest and have questions about it, you should raise these with the coroner’s office, details of how to contact the service are available on the Contact Information page.
If you have a question that is not answered here then please send us an e-mail to hmcoroner@leics.gov.uk and we will do our best to answer your query.
Page Last Updated: 11 June 2010
