This section applies mainly to England & Wales and Northern Ireland (where there are small differences). In Scotland the law on the investigation of deaths is quite different and will be described briefly below with links to further information.

Why are some deaths investigated?

In all of the UK, each individual is considered to be of such importance that there must be an explanation of why they have died. When a doctor knows why someone has died and the cause is known to be from a natural disease process, they will issue a Medical Certificate of the Cause of Death which allows the death to be registered and a funeral to be held.

However, it is quite common for people to die unexpectedly and there is no known cause. In the majority of these deaths, the cause is a natural disease process that was not known to the person or their doctor. Other people die as a result of accidents of various kinds, violence against them by others and also suicide.  The coronial system has been in place for many centuries to investigate unexplained and unnatural deaths and continues to provide an essential means of understanding why someone has died.

Coroners are a type of judge and all are trained in the law and some are also qualified doctors. Recent reforms have changed the way they work a little but in most cases they are responsible for geographical areas of the country. They are supported by coroners’ officers who carry out most of the day to day investigations and other administrative staff.

How are deaths investigated by the coroner?

Deaths are mostly referred to the coroner by police or a doctor, but anyone can report a death if they have concerns about the circumstances. The coroner’s team will gather essential information about the person who died and the circumstances of the death and this will include talking to the next-of-kin if at all possible as well as any doctor who has been treating the deceased person. Once it is clear there is no obvious cause of death, the coroner will ask for a post-mortem examination to be carried out. This is a careful external and internal examination of the body. The examination is carried out by specially trained doctors called histopathologists assisted by anatomical pathology technicians. The person who has died is treated with respect throughout and the body is carefully repaired so it is usually possible to visit the person in the funeral home after a post-mortem examination. If necessary, small samples of body tissues may be kept for examination under a microscope and the next-of-kin will be told if this has been necessary.

Post-mortem examinations of babies and children are carried out by specialist paediatric pathologists.

In some parts of the country it may be possible for the post-mortem examination to be carried out by a specialised scan. This is at the discretion of the coroner and may not be possible depending on the circumstances of the death. If a cause of death is not identified by the scan, there has to be a traditional post-mortem examination.

Provided the cause of death has been found to be from a natural disease process, the coroner’s office will inform the family of the results and forward the information to the registrar of deaths. The death can then be registered in the usual way.

All of this is normally completed within a few days so there is no major delay to registration or holding a funeral. However, it is wise not to confirm a date for the funeral without checking with the coroner’s office.

If the investigation of the death is to be more prolonged or there is be an inquest, the coroner will issue a Certificate of the Fact of Death. This enables who-ever is dealing with the estate to contact banks and other organisations and start the probate process if needed. You should also then be able to contact the registrar of deaths to obtain a unique code to use the Tell Us Once service. The coroner will usually also issue documents that allow the funeral to take place.

Deaths that are not caused by natural disease

People sometimes wonder why there has to be a post-mortem examination if it seems obvious that someone has died as the result of injuries sustained in a road traffic collision.  Firstly, it is important to ensure that no natural cause contributed to the collision e.g. a driver losing control of their vehicle following an unexpected heart attack.

The second reason is that careful documentation of the injuries can help explain how the accident happened, such as which part of a pedestrian was hit first and how they were moved by a vehicle. Often the pathologist is able to reassure the family that the nature of the injuries meant that the person who died lost consciousness very quickly and was not in pain for any length of time.

If a death is found to be from a non-natural cause, the coroner will hold an inquest. This is a formal court hearing where the coroner calls witnesses to give evidence on oath. It is different from other courts in that there is no prosecution or defence or contesting parties. The inquest has to determine who has died and how they came by the death. An inquest cannot attribute blame for a death but a coroner can require that organisations report to him or her on improvements in their procedures. One of the main reasons for an inquest is to learn from it and to help prevent future deaths in similar circumstances in the future.

Although an inquest is a formal court hearing, a coroner and his or her team are very aware of how difficult this can be for a family. There may be a delay of a few weeks or months before the inquest is held and it can feel like the clock has been turned back to the day of the death itself. However it is also a chance for the family to hear and understand, as far as is possible, what happened to their loved one.

Some courts are old and traditional in layout but others are in modern buildings. No-one wears wigs or gowns and the coroner will try and ensure that witnesses use plain English when giving their evidence or explain technical terms when they are necessary. The immediate family have the right to ask questions at an inquest but it is often easier to submit the questions you have to the coroner in advance of the inquest and the coroner will try and make sure they are answered if they are legally admissible. Information or questions not relevant to the death are not allowed.

Many courts use the Coroners’ Courts Support Service which helps care for families during inquests.

There are traditional ‘verdicts’ at the end of an inquest such as accident or misadventure but many coroners will now use a longer sentence to describe the circumstances of the death.

The coroner will forward all the information needed for registration of the death to the registrar and the family will be told when they can purchase death certificates if they require them.

The government has a very helpful guide for bereaved people coming into contact with Coroner Services which you can download. 

Deaths where the police are investigating

If police or other agencies such as the Health and Safety Executive have been involved in investigating the death, they will report their findings to the coroner. The post-mortem examination will be carried out by a pathologist with specialist forensic expertise.  If the Crown Prosecution Service is to prosecute someone for causing the death, the coroner will not hold an inquest, to avoid two courts examining the same death.  However, if no-one is charged in connection with the death, an inquest will be held and the finding may be that the person who died was killed by a person or persons unknown. 

If someone is to be prosecuted, they have the right to request an independent post-mortem of the body. If a coroner believes that someone may be prosecuted at a future date, they may order a second independent post-mortem examination so that this is available for the defence in the future. One of the reasons for doing this is so that the coroner can allow the family to make funeral arrangements.

A useful guide to Coroner's services can be downloaded Coroner Services Booklet

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