Evidence, oath and affirmations at an inquest
At the inquest, the 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 of his/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, or where there is a good reason for the witness not to attend the inquest.
The coroner has power to require documents and statements to be produced and failure to do so can result in fines.
Jury at the inquest
Most inquests are held without a jury but there are particular circumstances when a jury must be called:
– If a death occurred in custody or state detention and the death was violent or unnatural or the cause is unknown
– If the death resulted from an act or omission of a Police Officer
– If the death was caused by a notifiable accident, poisoning or disease
In every jury inquest the coroner decides matters of law and procedure and the jury decides the facts of the case and reaches a determination and findings. The jury cannot blame someone for the death. If there is any blame, this can only be established by the legal proceedings, in civil or criminal courts however, in some cases the jury can record facts which make it clear that the death was caused by a specific failure of some sort or by neglect.
Who decides which witness 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 by the ‘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 if the evidence is relevant to the investigation of the death.
Who can ask witnesses questions?
Witnesses will first be questioned by the coroner and then by any interested person or their legal representative. Whether a question is relevant to the purpose of the inquest is something the coroner decides.
All details are completed on the Record of Inquest by the coroner, or the jury, at the end of the inquest are ‘the determination and findings’. Sometimes a short form conclusion will be recorded by the coroner or jury. Commonly used short form conclusion include:
– Natural causes
– Accident or misadventure
– Industrial disease
– Open verdict (where there is insufficient evidence for any other conclusion)
The coroner is not obliged to make use of a short form conclusion. The coroner may use a variant or give a narrative conclusion which sets out the facts surrounding the death in narrative form.
Obtaining a record of the inquest
Once the inquest has been completed, an interested person may apply to inspect or obtain copies of any relevant documents. They may also request a copy of the audio recording of the inquest upon a payment of a £15 fee.
If you wish to obtain a copy of the recording please e-mail: firstname.lastname@example.org
Attendees with Special Requirements
The Court is wheelchair accessible however, we would appreciate if a prior warning is given so that appropriate arrangements can be made and security notified to provide assistance.
Translation/Interpretation and/or sign language
If you require a translator/interpretation and/or a sign language translator please notify us as soon as you are informed of the inquest so that this can be arranged to suit your needs.
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 interested persons. Interested persons and witnesses are not expected to present legal arguments.
The coroner must ensure that the process is fair, impartial, thorough and the relevant questions have of the interested persons have been 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:
a. There is a significant wider public interest in applicant being represented at the inquest
b. 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 efficiently and establish the facts, providing that the applicant was a member of the deceased’s immediate family.
Contact Legal Services
Tel: 0845 345 4345 or 0300 200 2020
What can you do if you are dissatisfied with the outcome of an inquest?
If you are dissatisfied with the outcome of the inquest there are two methods by which the 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 under section 13 of the Coroner’s Act 1988 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.
Once a coroner has reached a conclusion at the end of an inquest the Coroner is functus officio, i.e. the coroner ceases to have any further jurisdiction in the case and cannot re-open it, re-hear it or amend the conclusion. Anyone wishing to challenge the conclusion must do so by one or the other of the above methods.
All finders of gold, silver, groups of coins from the same finds, over 300 years old and prehistorical base-metal assemblages have the legal obligation to report the items to the coroner.
The coroner has the duty to inquire and to determine whether or not the find is indeed treasure. If you require further information regarding treasure please contact the Coroner’s Office directly or the British Museum. Information can also be found on the website listed below.
‘Interested persons’ and rights of the ‘interested person’
The categories of interested persons are set out in section 47 of the Coroner’s and justice Act 2009. Please see the following link for the detailed guidelines: Coroners and Justice Act 2009
The coroner decides who will be given interested person status.
Rights of interested persons, including bereaved people;
Interested persons involved in an inquest have the following rights:
– to be told the date, time and place of an inquest if one is needed.
– to ask relevant questions of 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.
– ask the coroner for a copy of the post mortem examination report or to arrange for it to be seen free of charge.
– ask the coroner about a separate post mortem examination. The cost of this examination, including any fee of the registered medical practitioner and mortuary charges, would be self-funded.
What is an inquest?
An inquest is a fact finding inquiry to establish who has died, how and when the death occurred. It is not a trial.
Unlike other courts there is no prosecution or defence. The coroner’s jurisdiction is inquisitorial rather than adversarial or accusatory. The coroner and others who are interested persons simply seek the answer.
An inquest will be opened as soon as the investigation reveals a need to conduct an inquest. This usually takes the form of a short public hearing at which evidence about the fact of death and the registration particular is usually given. Subsequently, a pre-inquest hearing may be arranged in complex cases, which is usually heard in public. The full inquest will then be resumed. 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 re-assumed and concluded.
What happens if someone is charged with causing the death?
In most circumstances when a person has been charged in connection with the death the coroner must suspend the investigation, usually until the criminal proceedings are concluded. 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.
If criminal proceedings take place the coroner will decide whether or not to resume the inquest. There may be no need if all the facts surrounding the death have emerged at a trial and in such cases the coroner will send another certificate to the registrar of deaths, confirming the outcome of the trial. If the inquest is resumed, however, the findings of the inquest as to the cause of death cannot be inconsistent with the outcome of the criminal trial.
Post Mortem (Autopsy)
A post mortem examination or autopsy is a medical examination of a body after death, carried out for a coroner. Most examinations performed in England and Wales are conducted by a pathologist of the coroner’s choice with the purpose is to establish the medical cause of death. All suspicious deaths are performed by forensic pathologists who are on the ‘Home Office List’.
The coroner does not require consent of relatives or other for a post mortem examination to be made. The coroner will inform ‘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 the deceased’s medical practitioner. Such persons are not entitled to be personally present but are entitled to be represented at the examination by a doctor of their choice and are responsible for any fees.
The Chief Officer of Police may also be represented at the post mortem examination if a notification is sent to the coroner.
Second Post Mortem
The coroner, if necessary, may arrange for a second post mortem.
If after the autopsy concerns remain about the cause of death, the relatives and other interested persons may ask the coroner for a further post mortem examination. Any such examinations would be at their own expense.
In cases where someone has died as a result of a criminal activity and a suspect has been apprehended who may be charged with a serious criminal offence, that person or their legal representation may request a further autopsy.
Is there an alternative?
Alternative methods of examining bodies after death, such as MRI, CT and minimally invasive post mortem are performed at a few specialist centres but are not widely available in all circumstances due to cause of death not being able to be established via these methods.
The coroner will, where at all possible, take into account religious and cultural needs.
Retained tissue and organs after a post mortem
Pathologists cannot always determine a cause of death by macroscopic examination at autopsy. They may need to perform further tests in order to ascertain the cause of death by taking small pieces of tissue to examine under the microscope, taking blood or other body fluids for further tests they see necessary.
At times it may be necessary to take whole organs for further examination, the heart or brain may need to be examined by a specialist pathologist especially in cases where healthy individuals have died suddenly and unexpectedly.
Pathologists may only take material that have a bearing on the cause of death. There are strict rules around taking material from a body at autopsy and the pathologist must inform the coroner, the coroner will inform the relevant interested person and offer the following three options:
a. Material to be disposed of when it has served its purpose
b. Return of material to the deceased’s family or representative
c. Consent for the material to be retained for medical research or other purposes
In cases involving homicide tissue or whole organs may have to be retained by the Crown Court. Other statutory provisions apply, such as the Police and Criminal Evidence Act or directions of the trial judge.
Further information regarding tissue retention and legal requirements relating to consent can be obtained from the Human Tissue Authority at www.hta.gov.uk
Post Mortem report
The report gives details of the examination that was made of the body and details of any tests that have been performed as part of the cause of death investigation. It is sent to the coroner by the person who carried out the post mortem examination.
Copies of the report are normally available only to the interested persons, though its contents may be disclosed during the investigation and inquest in some circumstances a coroner may close an investigation after a post mortem examination if the investigation reveals that the cause of death was natural and there were no circumstances that required an inquest to be held. The coroner will release the body for the funeral and send a form to the registrar of births and deaths stating the cause of death as disclosed by the post mortem examination. The death can then be registered
How to register a death
When someone dies in England and Wales the death has to be registered, deaths are registered by:
– a registered medical practitioner in attendance during the final illness of the person who dies will issue a medical certificate of the cause of death certifying a natural cause of death that is acceptable to the local Registrar of Deaths
– where that is not possible for any reason, the death must be reported to the local coroner and he or she may then issue a certificate after appropriate investigations or after an inquest has been held. This certificate will then allow the registrar to register the death
Prevention of future deaths
Sometimes the evidence at an investigation or inquest will show that something could be done to prevent future loss of life. If so, the coroner may announce that she will draw this to the attention of any person or organisation that may have the power to take action. This is sometimes referred to as a ‘PFD Report’. The power to make such a report is found in the 2009 Act.
Anyone who receives such a report must send the coroner a written response within a prescribed time period. These reports and the responses to then are copied to the interested persons and the Chief Coroner. A summary of the reports is published twice a year by the Ministry of Justice and the reports are published on the Chief Coroner’s website.
Taking a body abroad or bringing a body back from abroad
- 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 investigation, inquest or post mortem examination is needed and will notify the deceased’s family with a decision within four days.
The coroner may need to investigate the death and may be required to hold an inquest. When the death has occurred outside England and Wales and the body is returned to England or Wales, the death is not registered by the registrar or 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 Officer’s website fco.gov.uk/en/travel-and-living-abroad/when-things-go-wrong/death-abroad
Request for Inquest documents, archives and Genealogy
Coroner’s files only have to be kept for 15 years after which only 10% of sample files are kept. An archive search can be arranged at the discretion of the coroner however, it is important to note that there is a fee of £15.00 whether or not the search is successful.
Local newspapers can be a source of information; the local archivist may be able to assist with tracing old news reports.
If the death took place over 75 years ago the record may not be suitable for release and would only be considered to be released to those who could claim a proper interest. The boundaries of jurisdiction have altered over recent decades, making it problematic to establish the probable venue where any exact records are held and it is also important to note that during the World Wars many records were destroyed.
The court does not offer genealogy searches.
Our jurisdiction area
South London Coroner’s Area is
Bromley, Bexley, Sutton, Croydon
- how personal information is obtained
- what it is used for
- who it might be shared with and why
- how long it is kept.
The information you provide helps us deliver our services effectively.
Personal and special category data
The categories of personal data we are processing are:
- date of birth
- medical history from the GP and hospitals
- cause of death
- family details
- lifestyle and social circumstances
- financial details
- employment and education details
- occupation and place of work
- offences and alleged offences contained in police report
- physical or mental health details
- racial or ethnic origin
- religious or other beliefs
- criminal proceedings, outcomes and sentences
- results of DNA reports and finger reports results
- juror information – name, address, bank account details – to pay expenses
- witnesses – name, address, bank account details – to pay expenses.
The Senior Coroner for the South London Jurisdiction is the data controller for the purposes of the Data Protection Act 2018 and the General Data Protection Regulation (GDPR) (Regulation (EU) 2016/679).
You can find details for the London Borough of Croydon Data Protection Officer (DPO) on our website https://www.croydon.gov.uk/democracy/data-protection-freedom-information
We ensure that your personal data is accurate, processed fairly and lawfully, kept secure and retained for no longer than is necessary.
The legal basis for processing personal data
The Senior Coroner must investigate all deaths which are violent or unnatural, where the cause of death is unknown, and where a death occurs while in custody or state detention.
Your personal data is collected to enable us to administer the running of the Coroner’s Office and carry out our statutory responsibilities under the different legislative frameworks.
In addition, we collect your personal data for:
- service delivery
- statistical analysis and reporting
- safeguarding (future prevention of death).
How we use your personal information
When deciding what personal information to collect, use and hold, we are committed to making sure that we will:
- only collect, hold and use personal information where it is necessary and fair to do so
- keep your personal information secure and safe
- securely dispose of any personal information when it is no longer needed.
We collect this data because we are required to under:
- the Coroners Act 1988
- the Coroners and Justice Act 2009 and its subordinate legislation
- other legislation appertaining to the administrative and judicial functions of the Coroner.
Who we share your information with
As inquests are accessible to the public, this data will be shared with anyone attending the proceedings, including the press.
The Senior Coroner may share data with:
London Borough of Croydon
London Borough of Bromley
London Borough of Bexley
London Borough of Sutton
The Chief Coroner
Other coroners – specifically those where cases are often transferred to or from
NHS Hospital Trusts
Clinical Commissioning Groups covering Sussex
Ministry of Justice
London Fire Brigade
British Transport Police
London Ambulance Service
Crown Prosecution Service
Health and Safety Executive
Accident investigation branches
Registration of Births and Deaths office staff
Coroner’s Court Support Service
Local authority support staff
Cemeteries and crematoria
Families affected, appointed executor representative of the person whose personal data we are processing
Financial organisations, such as insurance companies and pension schemes
Other organisations, which from time to time are involved with an investigation and who are required to provide evidence or assistance to the Coroner.
We primarily receive data from MET Police, NHS Hospital Trusts GPs and Registry Offices; however, data will be received from other organisations listed above. The data we have includes personal details and/or sensitive classes of data.
We will not share data with third parties for marketing purposes and it will not be transferred abroad.
How long we keep your personal data
Deaths that are reported to the Senior Coroner for South London Jurisdiction are held for a minimum of 15 years.