The coroner and inquests

Who is the coroner?

A coroner (the procurator fiscal in Scotland fulfils a similar but not identical role) is an independent officer with legal powers working on behalf of the Crown. Most coroners and all procurator fiscals are lawyers but some coroners may be doctors.

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

The coroner's role is to inquire into deaths reported to them which may be unnatural for any reason or of unexpected and unknown cause. Deaths are mainly reported to a coroner by the police, registrars of deaths and doctors.

If a member of the public has a concern that a death is not natural they should contact the police as soon as possible.


The first steps in the coroner's enquiries

The coroner or his/her officer will gather information about the death to determine whether a doctor can issue a medical certificate or whether further investigations are required. If a medical certificate cannot be issued the coroner will usually order a post mortem examination.

If a coroner's post mortem examination reveals that the death was due to natural causes and that an inquest is not needed, then the coroner will release the body, the death can be registered and the funeral can then take place.

Inquests

If the cause of death remains in doubt after a post mortem examination or the post mortem examination confirms that the death was not from natural causes, an inquest (in Scotland a ‘fatal accident inquiry') will be held. If there is to be an inquest, the coroner can normally issue a burial order or cremation certificate after the examination is completed. If charges have been brought against somebody for causing the death, it may be necessary to have a second post mortem examination or further investigations, and the funeral arrangements may be delayed.

When the coroner's investigations are complete, a date for the inquest is set and the people who need to know will be told. Inquests are open to the public and journalists are usually present.

There are certain cases where a coroner is obliged to hold an inquest even when the death is from natural causes, such as when someone has been in custody at the time of death.

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

Anyone with a legitimate interest is also allowed to question witnesses at an inquest. It is very important that the coroner is made aware before the inquest of anyone who believes they have a legitimate interest and the nature of their questions.

Inquests do not determine blame and the verdict must not identify someone as having criminal or civil liability.  Possible verdicts include: natural causes; accident; suicide; unlawful or lawful killing; industrial disease and open verdicts (where there is insufficient evidence for any other verdict). Sometimes a coroner does not use one of these short phrases but gives a longer sentence describing the circumstances of the death - this is called a narrative verdict.

The coroner may also report the death to any appropriate person or authority such as the Health and Safety Executive, if action is needed to prevent more deaths in similar circumstances.

At the close of the inquest the coroner forwards information to the registrar of births and deaths to allow the death to be registered and the family can then purchase death certificates from the registrar. This can be done by post if the family live at some distance from the registration office.

Call us for help with finding your nearest coroner's office.