Chief Coroner’s Guidance and Law Sheets

Inquest Representation ServiceThe coroners of England and Wales are led by a Chief Coroner who sets down guidance and advice for effective management of inquest cases. So far, the first Chief Coroner, Sir Peter Thornton QC and his successor HHJ Mark Lucraft QC have issued 36 pieces of guidance on specific subjects relating to the inquest process:

  • The use of post-mortem imaging (adults)
  • Location of Inquests
  • Oaths and Robes
  • Recordings
  • Reports to Prevent Future Deaths
  • The Appointment of Coroners
  • A Cadre of Coroners for Service Deaths
  • Pre-Signed Forms
  • Opening Inquests
  • Warnings to Juries
  • Juries in Railway Cases (Suicides and Accidents)
  • The Inquest Checklist
  • Family Court Proceedings Findings of Fact
  • Mergers of Coroners Areas
  •  Apparent Bias
  • Deprivation of Liberty Safeguards (DoLS)
  • Deprivation of Liberty Safeguards (DoLS) from 3 April 2017 onwards
  • Conclusions: Short-form and Narrative
  • Section 1(4) Reports: Investigation without a body
  • Mentors for coroners
  • Core competencies for Assistant Coroners
  • Core competencies for Assistant Coroners form
  • Translators and Interpreters
  • Pre-Inquest Reviews hearings
  • Report of Death
  • Transfers
  • Coroners and the Media
  • Organ Donation
  • Jury Irregularities
  • Report of Death to the Coroner: Decision Making and Expedited Decisions.
  • Documentary inquests
  • Judge-led inquests
  • Death Referrals and Medical Examiners
  • Post-Mortem Examinations including Second Post-Mortem Examinations
  • Suspension, Adjournment and Resumption of Investigations and Inquests.
  • COVID-19
  • Hearings During the Pandemic
  • Summary of the Coronavirus Act 2020 Provisions Relevant to Coroners
In addition there is:
  • Chief Coroner Joint Guidance on Sudden Cardiac Death -Inherited Heart Conditions

For more information about the Chief Coroner’s guidance, Read the Chief Coroner’s Guidance

In Brown v HM Coroner for Norfolk [2014] EWHC 187 admin –  the court gave guidance on Pre-Inquest hearings. Read the court judgment

Some salient points from the Guidance, of note:

  • An inquest can be held outside the coroner’s district in exceptional circumstances such as lack of available and suitable court space. The coroner should take account of the views of the interested persons and the distances they may have to travel.
  • It is not necessary or appropriate to wear robes in any hearing. All coroners should reflect the good practice of the vast majority of coroners who do not wear robes.
  • All inquest hearings must be recorded – this includes pre inquest review hearings, and where practicable openings.
  • Hearings should be recorded on a court recording device rather than using a stenographer.
  • Coroners should inform bereaved families that they are entitled to ask for a copy of the recording after the inquest. On request the coroner must provide a copy of the recording or make the recording available for inspection (subject to the Regulations on disclosure).Inspection means listening to the recording at the coroner’s office.
  • In relation to information stored in archive a copy of the recording may be supplied to “any person who in the opinion of the coroner is a proper person to have possession of it” (Reg 27(2) Coroner’s (Inquests) Rules 2013. )The coroner has a discretion whether to provide a copy. This should be done on a case by case basis.
  • Where a copy of the recording is supplied for the purpose of producing a transcript, the transcript must be shown to the coroner before it is used in any further proceedings so that the coroner can check it.
  • Transcripts should not normally be supplied by the coroner unless it has been necessary to redact the recording. If the recording cannot be redacted a transcript should be obtained a redacted before a copy is supplied.
  • By law coroners no longer need to make and keep their own notes of hearings. If they do these are no longer disclosable and cannot be inspected.
  • PFD reports (reports to prevent future deaths) are important. Coroners have a duty not just to decide how somebody came by their death but also, where appropriate, to report about that death with a view to preventing future deaths. A bereaved family wants to be able to say: ‘His death was tragic and terrible, but at least it shouldn’t happen to somebody else.’
  • The coroner is under a duty (not just a discretion) to make a PFD report when a concern arises.
  • In concluding there is a concern the coroner is no longer restricted to matters that arise in the evidence at the inquest. The whole investigation is covered.
  • PFD reports should be intended to improve public health and safety. They should be brief, clear, focused, meaningful and wherever possible designed to have practical effect.
  • A report is essentially ancillary to the primary purpose of an inquest which is to determine the statutory findings and conclusions related to the death.
  • Sometimes it may be necessary to hear some evidence which may be relevant for the purpose of making a PFD but not strictly relevant to the outcome of the inquest. Adding to the inquest with additional lengthy evidence should be avoided. An inquest is an inquest not a public inquiry.
  • The PFD need not be restricted to matters causative (or potentially causative) to the death in question.
  • A PFD report is a recommendation that action should be taken, not what the action should be.
  • A coroner must use the template for a PDF not write a letter.
  • Opening an inquest will be less urgent because coroners are now allowed to release the body for burial or cremation without having to open an inquest.
  • If the case is one where the coroner must hold an inquest, as a matter of good practice the coroner should notify the family of the deceased of the date, time and place of the opening in all cases. It may also be good practice to notify others who may have an interest in the proceedings.
  • An opening should be in public. Subject to certain caveats a coroner who sits in private to do this does so without jurisdiction with the proceedings liable to be quashed. Difficult logistics should not be used as an easy excuse for not opening in public.
  • The opening of an inquest should be recorded and the recording kept. This applies if the inquest is opened in private.
  • At the opening the coroner will receive evidence of identification. The coroner may also hear brief evidence of the general circumstances of the death, the finding of the body, whether a post mortem has taken place, and the provisional medical cause of death (if known). Care should be taken not to give the impression at an opening that a final conclusion has been reached on any issue.
  • Because the rules impose a duty on the coroner to complete an inquest within 6 months of notification of the death at the opening the coroner must where possible fix a date for the inquest or for a review hearing. Where it is not possible to complete the inquest within 6 months coroners must still complete the inquest as soon as reasonably practicable.
  • Whenever a coroner fixes the date for a review hearing he should state what is intended to be achieved at the hearing. See also Brown v HM Corner for Norfolk [2014] EWHC 187 admin, above.
  • The importance of setting dates cannot be over-emphasised. If it is not possible to fix a final hearing date, a review hearing date should be set when all outstanding issues can be addressed.
  • As well as fixing a date the coroner should give directions when feasible including a time table for the provision of reports and statements particularly those of a medical nature. Usually the coroner should direct that they should be received within 6 weeks.
  • Notifying the public in advance of the details of a final inquest hearing should be done by publishing on a web site. If this is not possible details should be posted regularly outside the court.
  • Once opened an inquest must be concluded.
  • Coroners must not pre-sign forms. This covers all forms whether urgent or not where the coroner is by his signature signifying or recording a judicial decision. No-one else (such as a coroner’s officer) must fill in a form since it is part of the judicial function.
This case has been reflected in the Chief Coroner’s Guidance No 22 : Pre-Inquest Review hearings.

Guidance No 28 was issued as a result of the High Court decision in the AYBS case (Adath Yisroel Burial Society) [2018] EWHC 969 (Admin) [ see Case Summaries]. This is to assist coroner’s where a bereaved family makes a request for urgent consideration of the death and/or an early release of the body, or, the coroner or coroner’s officers become aware of particular features of the death which may justify treating it as especially urgent.

Law Sheets: The Chief Coroner issues Law Sheets that focus on the law in certain key areas. These are amended as necessary to reflect recent decisions in case law. So far there are 5 Law Sheets.
     . Law Sheet No.1: Unlawful Killing
     . Law Sheet No.2: Galbraith Plus
     . Law Sheet No.3: The Worcestershire Case
     . Law Sheet No.4: Hearsay Evidence
     . Law Sheet No.5: The Discretion of the Coroner

INQUESTS AND COVID-19. The Chief Coroner has issued 3 pieces of Coroner’s Guidance 34,35, and 36 addressing the effects of the pandemic on deaths, registration and the impact on the coronial investigation process in England and Wales [see the Inquests News page for a more detailed summary.]


Inquest Representation Service provides legal advice and representation in all areas of coronial and inquest law. To see how one of our inquest law lawyers may be able to assist you, contact us without obligation and in strict confidence on: 033 00 77 00 97

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