What does a Coroner do?

Inquest Representation ServiceThere is a hierarchy of coroners across the country, led by the Chief Coroner nationally. There is a senior coroner in each district.

The Senior Coroner for each designated area has several administrative roles. He must keep a register of everyone who dies in his area. If he is conducting an investigation into a death he can issue on interim certificate of the fact of death to the deceased’s next of kin or personal representative. Where the coroner feels a post mortem is required it is his responsibility to request a suitable practitioner to make that post mortem examination as soon as reasonably practicable. There is a list of people including the deceased’s next of kin and personal representative that he must notify of the date, time and place when the post mortem examination is going to take place. This is so that they can attend and bring their own medical representative should they wish to do so. If the coroner is conducting an investigation into a death he is responsible for issuing an order to permit the release of the deceased’s body for burial or cremation once he has concluded that the body does not need to be retained for the purpose of the investigation. A coroner can issue a direction for the exhumation of a body after burial.

Coroners carry out an important function in investigating deaths that occurred in certain circumstances. They are; where there was a violent or unnatural death, the cause of death was unknown, or the death occurred whilst in custody or other state detention.  A lot of these investigations will require an inquest hearing into a death. There is also a Coroner for Treasure and Assistant Coroner for Treasure who investigate treasure applications or cases of suspected treasure under the Treasure Act 1996 and may have to conduct a treasure inquest. Until Chapter 4  of the Coroners and Justice Act 2009 comes into force any coroner can conduct a treasure investigation and treasure inquest. These are judicial roles of the coroner.

For the first time in decades the whole coroner’s system was reviewed and overhauled by the Coroners and Justice Act 2009. As at September 2013 not all of the provisions in the Act pertaining to coroners and inquest law have come into force but the key changes to create a new structure and system of governance have done. There is now a Chief Coroner who has the role of overseeing governance at a national level. The Chief Coroner’s appointment is for a fixed term. The current Chief Coroner (the second person to be appointed to the role, since the inception of the position) is Mark Lucraft QC. The role of Chief Coroner includes (but these are not their only functions) setting national standards, developing training for coroners and their staff, and approving all future appointments of coroners.  The Chief Coroner has issued guidance across a range of specific subjects. See our summary page on the guidance: Chief Coroner’s Guidance. The coroner for a designated area is the Senior Coroner and he can be supported by Area or Assistant Coroners.  All newly appointed coroners must be lawyers who satisfy the judicial appointment eligibility conditions, appointment is on a 5 yearly basis and the appointee must be under 70 years of age. Medical doctors can no longer apply for a coroner’s post.

Previously a coroner had to deal with a death if it occurred within his jurisdiction. Now there is new flexibility with the power to request the coroner in another area to conduct an investigation into a death. The Chief Coroner can direct that an investigation is transferred to another coroner. It will be interesting to see how this power is used. For example will one Senior Coroner within a geographical area take on all deaths in custody so that it becomes the recognised centre for those types of cases?

A lot of investigations into a death involve a considerable amount of work for the coroner and coroner’s office in trying to identify the evidence the coroner needs and then gathering it, reviewing it and deciding what other case management decisions need to be taken. For example, does the coroner need to instruct an independent expert? Does the coroner need to call an inquest or a pre inquest hearing? If so, is it a standard inquest or is it an enhanced inquest because there are issues relating to Article 2 of the European Convention on Human Rights, where a jury is needed? Who needs to attend to give evidence at the inquest? For each investigation into a death the coroner will have a Coroner’s Officer. He / she is there to help the coroner with all the administrative side of the investigation or preparing for an inquest hearing. The Coroner’s Officer is often the main line of communication for the family of the deceased, other interested persons, and any legal representatives. Although the Coroner’s Officer plays a key administrative role all judicial decisions have to be made by the coroner.

During an inquest hearing the coroner is responsible for how it will be conducted.  For example, should a witness give evidence from behind a screen or be asked to wait outside until it is his turn to give evidence? It is a fact finding process where the coroner takes the lead in asking witnesses questions to elicit their evidence. Other interested persons or their legal representatives then have the opportunity to ask questions. If there is a jury it is the coroner’s duty to direct them on the law and to provide them with a summary of the evidence. In essence not only does the coroner have to make sure that the jury are properly directed on the verdicts that might be available in a particular case, but he needs to decide  how best to elicit the jury’s conclusions on the central issues of the case.  See R (P) v H M Coroner for Avon [2009] EWCA Civ 1367Read the report.

At the end of an inquest hearing, if the coroner has conducted it by himself without a jury he has to fill in the Record of Inquest Form. This sets out the information that the Coroner is legally required to ascertain during the inquest hearing, including the verdict. The verdict will either be a recognised short form such as “natural causes” or “suicide”, or may be a brief narrative verdict.

The primary purpose of an inquest hearing is to answer the questions required by law: who, how, when and where the deceased came by his death. However, the coroner has an ancillary role which in certain types of cases can be important in trying to prevent future deaths from occurring in similar circumstances. He is under a statutory duty to make a Report to Prevent Other Deaths if anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and in his opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances. The coroner must report the matter to a person who the coroner believes may have power to take such action. The organisation or body who has a duty to respond to the Report has to do so within 56 days giving details of any action that has been taken or which it is proposed will be taken, or give an explanation as to why no action is proposed. The Coroner can only make such a report once he has concluded his investigation and reviewed all the evidence.


The Lawyers at Inquest Representation Service are experienced in giving advice and providing representation to individuals and business organisations who find themselves involved in a coroner’s investigation or inquest hearing.  If you would like help or further information please contact us on 033 00 77 00 97. All enquiries are treated in strictest confidence and are free of obligation.


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