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Coroners & Inquests

The involvement of the police in the investigation of a sudden death, especially if there are apparently no suspicious circumstances, may cause alarm. This section explains why the police are involved, and describes the responsibilities and work of the Coroner.

The Coroner

It is in everybody’s interest that sudden or unexplained deaths are investigated, and to do this every County has one or more Coroners, who are experienced lawyers or doctors independent of both local and central government. A Coroner has his or her own Coroner’s Court, funded from the council tax, which is governed by law and special rules of procedure. Coroners must be available (or arrange for suitably qualified deputies to be available) at all times.

Coroners are assisted by a small staff of Coroner’s Officers and, in addition, police officers are sometimes required to assist, by making reports or carrying out enquiries.

Police officers also have a duty to investigate any suspicion that a criminal offence may be linked to or caused the death.

Not all deaths have to be reported to the Coroner. In most cases the deceased’s own doctor or the doctor in hospital who was treating him or her will be able to supply a medical certificate of the cause of death. But some deaths must be reported to the Coroner.

  • When no doctor has treated the deceased during his or her last illness, or
  • When the doctor attending the patient did not see him or her within 14 days before death, or after death, or
  • When the death occurred during an operation or before recovery from the effect of an anaesthetic or
  • When the death was sudden an unexplained or attended by suspicious circumstances, or
  • When the death might be due to an industrial injury or disease, or to accident, violence, neglect or abortion, or to any kind of poisoning, or
  • When the death occurred in prison or in police custody

If a death occurs in any of these circumstances it is usually reported to the Coroner by the police, or the doctor who was called to the death if it was sudden or accidental, or the doctor who was treating the person who died if the death was unexpected. If the report was not made by any of these, the Registrar of Deaths must make the report. The Registrar is not allowed to register a death until the Coroner’s enquiries are complete. Enquiries can take some time and it is always best to check with the Coroner’s office before making funeral arrangements.

If a police officer takes the report of the sudden death, he or she may arrange for the body of the deceased to be taken away by a funeral director appointed by the police. This does NOT mean that you have to use the same funeral director when making arrangements. You may contact a funeral director of your choice at any time but tell them that the Coroner is involved so they know that there may be a delay. Funeral directors are familiar with the Coroner’s procedure and can offer advice to the bereaved.

It will be necessary to arrange for someone who knew the deceased person to make a formal identification of the body. This can be done in different ways, but usually a relative of the deceased is asked to visit the Chapel of Rest at the hospital and view the body. This can be a distressing and traumatic experience, and it may be helpful to have the support of a friend or close relative when the identification is made. However, many people appreciate the opportunity to be with their loved one for a last time, and the hospital authorities try to arrange for the setting to be both private and sympathetic.

The Coroner may be able to establish that death was due to a natural cause and there is a doctor who is able to certify the cause of death. If this is not the case the Coroner arranges for a post mortem examination to be made. The examination often shows that the death was due to natural causes and in such case there is no inquest. The Coroner sends a certificate to the Registrar of Deaths so that the death can be registered. Alternatively, after registering the death, the Registrar can issue a certificate for burial or cremation. If the death is not due to a natural cause, however, the Coroner is obliged by law to hold an inquest.

The Inquest

The Coroner will normally open an inquest a few days after the death when the result from the post mortem examination is received. The Coroner will hear evidence of identification, usually by way of a written statement, and will then adjourn the inquest to a later date when all the relevant evidence has been collected. No next of kin or witnesses are required to attend at this stage. They will be informed when the date for the full inquest has been fixed. The Coroner will then normally issue a burial or cremation certificate so that the funeral arrangements can proceed.

The inquest is not a trial to establish someone’s guilt; it is an enquiry to establish the facts. The purpose of the inquest is to ascertain the identity of the deceased, when, where and how the death occurred, and to establish the details that have to be registered by the Registrar of Deaths.

In the few cases when an enquiry shows that the death might be due to murder, manslaughter or infanticide, the Coroner must send the papers to the Director of Prosecutions. The police will be able to advise you if this is the case.

If somebody has been charged with an offence of murder, or manslaughter, causing death by dangerous driving, complicity in another’s suicide, or infanticide, the in quest is adjourned until criminal proceedings are completed. Before adjourning, the Coroner establishes the identity of the deceased person and medical causes of death and sends a form to the Registrar of Deaths so that the death can be registered.

Any other court proceedings will normally follow the inquest. When all the facts about the cause of death have been established at the inquest, a person may be brought before any other court, or a claim for damages made. The inquest may be of help to the family of the deceased, in finding out what happened. In the case of an accident at work, it can also help to avoid similar accidents in the future. If the inquest finds that the death occurred in circumstances where there is a possibility of further deaths from the same cause, the Coroner can draw attention to this publicity and bring the matter to the attention of the appropriate authority.

There may or may not be a jury at the inquest. If the death was caused by an accident or disease which must be notified to the government, as in the case of industrial accidents, for example, or if the deceased died in prison or in police custody, or if the death may have been caused by a police officer carrying out his or her duty, then there must be a jury. In other cases a jury may be summoned if the Coroner thinks it may be of assistance. If a jury is summoned, it is the jury, and not the Coroner, who returns a verdict. Between seven and eleven jurors are summoned and they can give a majority verdict when no more than two disagree. Jurors are not expected to view the body.

The Coroner decides which witnesses should be asked to attend the inquest and the order in which they should give their evidence. The evidence of a witness may be vital to prevent an injustice and, to ensure that witnesses do attend, they may be asked or even summoned to the inquest, and penalties may be imposed for failing to attend.

A witness at the inquest may be questioned by any person who has a ‘proper interest’.

This group includes:

  • A parent, spouse, child and any personal representatives of the deceased;
  • Any beneficiary of a policy of insurance on the life of the deceased, and any insurer having issued such a policy;
  • Any person whose acts or omission on the part of himself or his or her servants or agents, irrespective of whether it may give rise to civil liability, may, in the opinion of the Coroner, have caused or contributed to the death of the deceased.
  • The chief officer of police (who may only examine witnesses through a lawyer).
  • Any person appointed by a Government Department to attend the inquest.
  • Any person appearing to the Coroner to have a proper interest.
  • The Coroner’s Office will advise you whether you have a proper interest.

In addition, a person with a proper interest in the inquest may apply to see the Coroner’s notes after the inquest or may obtain a copy on payment of a fee.

The body can be buried, cremated or taken out of England and Wales as soon as the Coroner is satisfied that no further tests are needed and the necessary certificates have been issued. If an inquest is held, the Coroner can give an order allowing the burial or cremation of the body as soon as any necessary examination has been completed. If a person has been charged with an offence in connection with the death of the deceased, the Coroner gives the defence an opportunity to examine the body.

The death can be registered and a death certificate issued only after the Registrar of Deaths has received the Coroner’s written approval at the end of the inquest or when it is adjourned after someone has been charged with causing the death. If the inquiry is difficult or lengthy, the Coroner may provide a letter explaining the circumstances and the death cannot be registered until the inquest has been completed. This may be acceptable for the payment of insurance money and the administration of the estate.

The Coroner, because he or she is concerned with the investigation of death, must give consent before organs are removed for transplant. This is because removal may affect some important evidence. The consent of the Coroner can usually be obtained quickly.

The Coroner must be notified in every case where it is proposed to take a body out of England or Wales (for burial abroad, for example), whether or not there has been an inquest, and he must give permission for the body to be taken out of England and Wales.

Are Inquests held in Public?

Inquests are held in public, and the press can be present. Everything is in the open and no facts are concealed, but the Coroner knows that every death is a human tragedy and deals with each sympathetically. Suicide notes and personal letters are not read out in court unless absolutely necessary, and efforts are made to spare the feelings of the bereaved. The inquest seeks to present the truth, and to dispel rumours or untrue stories concerning the death, and this means that in the interests of justice it is sometimes unavoidable that the proceedings are upsetting.

For More Information

Contact the local Coroner’s office using the number listed under ‘Coroner’ in the telephone directory. Your local police station or the Citizen’s Advice Bureau may also be able to help. They should have access to a range of helpful leaflets and other information available for the bereaved, and may be able to help you to contact specialist support organisations.


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Malik, son of Dinar, said: Jesus, peace be upon him, and his disciples with him passed by the carcass of a dog.  A disciple said "What a stench this dog makes!"  Then he, (blessings and peace be upon him) said "How white are its teeth!".