Click here for: A Guide to Coroner Services for Bereaved People

A coroner is an independent judicial office holder. The Coroner’s Office must be available at all times to address matters relating to an investigation which must be dealt with immediately and cannot wait until the next working day.
The legislation governing the coroner is contained in the Coroner’s and Justice Act 2009, the Treasure Act 1996 and a number of pieces of subordinate legislation.  There is also a considerable body of case law governing the way in which a coroner operates.

Coroners inquire into violent and unnatural deaths, deaths of unknown causes, deaths which have occurred in custody or otherwise in state detention and certain other categories specified in the Coroner’s and Justice Act 2009.  A coroner’s authority to inquire flows from the report of the fact that a body lies within the coroner’s area; 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 the coroner’s duty at an inquest to establish who the deceased was and how, when and where the death occurred.  After an inquest, if the death occurred in England or Wales, the coroner will send the necessary details to the registrar of births and deaths for the death to be registered.  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.

In some cases a death may be referred by the coroner to the Police for investigation on the coroner’s behalf.  In other cases a separate investigation into a death may be undertaken by an independent body such as the Health and Safety Executive the Prison and Probation Ombudsman, the Care Quality Commission, the Independent Office for Police Conduct and so on.

Coroners also have jurisdiction over Treasure.

Role of the Coroner

Registrars of births and death, doctors, police and others report deaths to the Coroner in certain circumstances.  Not all deaths need to be reported to the coroner.  In many cases the deceased person’s GP, or hospital doctor who has been treating them 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.  At times, the doctors may discuss the case with the coroner and this may result in the coroner declining further inquiries into the death, 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 a certificate 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 want for the coroner to finish all 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.


Role of Coroner’s Officers 

Coroner’s Officers work under the direction of the coroner and liaise with bereaved families, pathologists, the police, doctors, witnesses, funeral directors and others.  Coroner’s Officers receive reports of deaths and make inquiries at the direction, or on behalf, of the coroner.