Coroners and Inquests: Coroners

What Is a Coroner?

Coroners have been an essential part of English law for centuries: the role was first established as far back as 1194.  A Coroner is an "independent judicial officer", which means that he or she has a similar position to that of a Judge.  There is a common misconception that Coroners are medical examiners who perform autopsies; this job is done by pathologists. 

Coroners are legal officers, who take charge of the investigation of deaths.  Coroners are appointed and funded by Local Authorities but, ultimately, they are responsible to the Crown, so their procedures should be independent of political influence.  The law states that all Coroners must be lawyers or doctors of at least 5 years' standing.  Most Coroners have a legal background.  Local councillors are prohibited from holding the Coroner's office.

What Do Coroners Do?

The primary duty of a Coroner is to establish the cause of death in cases that have been reported to him or her.  It is not the Coroner's job to apportion blame as to the cause of death, but to make a factual finding regarding the identity of the deceased, and when, where, and how he or she died.

In some cases, the Coroner is able to satisfy him or herself as to the cause of death by making fairly informal enquiries.  For instance, it may be that the deceased's GP is able to supply information that enables the Coroner to conclude with confidence that the death was of natural causes.  In these relatively straightforward cases, the Coroner can simply issue a death certificate, and need not pursue any further investigations.  The body of the deceased will be released.

In other cases, more detailed enquiries are demanded, including a post-mortem examination and/or an Inquest.  An explanation of these procedures is given below.

What Deaths Are Reported to the Coroner?

Coroners can only investigate cases in which the body of the deceased is lying in his or her district.  It does not matter where the deceased actually died (they may even have died abroad): the Coroner with responsibility to investigate a death is the one who looks after the area in which the body is physically present.

There are precise categories of death that have to be investigated by Coroners but, broadly speaking, the key circumstances under which a Coroner will be involved are when a death appears to have been sudden, suspicious, violent, or unnatural.

Anyone who believes that a given death should be investigated can inform his or her local Coroner about it.  The only people who are legally obliged to report deaths to Coroners are Registrars of Births and Deaths.  When they are asked to register a death, Registrars have to notify the Coroner if the circumstances of death are of the kind that should be investigated, especially if the Registrar cannot provide a conclusive cause of death for the death certificate.  There is a link to the legislation that governs Registrars' precise responsibilities below.

In practice, however, most cases are referred to Coroners by doctors or the police, who know from experience what deaths will be notified to the Coroner.  Research shows that only about 1 in 50 Coroners' cases are referred by the Registrar.

Doctors report deaths to the Coroner whenever they are unable to provide a precise cause of death for the deceased's death certificate.  They are also obliged to notify the Coroner of any death that "appears... to have occurred during an operation or before recovery from the effect of an anaesthetic" (again, strictly speaking, it is the Registrar of Births and Deaths who is subject to these regulations, but doctors know which cases will be referred on to the Coroner, and normally take this step themselves).  This is generally interpreted to mean that any death that occurs during - or within 24 hours of - an operation should be reported to the Coroner.  Frequently, the cases of patients who die in hospital are referred to the Coroner as a matter of routine, unless the treating doctors can be very sure of the precise reason why their treatment has failed.

On average, about 200,000 deaths per year in England and Wales (around 3/8 of the deaths that are registered) are reported to the Coroner.

Where Can I Find my Coroner?

The easiest way to find out who your local Coroner is, and how to contact him or her, is to look in your telephone directory (under "Coroner").  You could also ask your local Police, or contact the Home Office (tel: 0870 000 1585; e-mail: public.enquiries@homeoffice.gsi.gov.uk).  Inexcusably, there is no on-line source of information that is kept up-to-date; the most current list of Coroners is hidden in an appendix to the Code of Practice to the Treasure Act, which you can access on the website of the Department for Culture Media and Sport.  Do be aware, however, that this list may well include some out-of-date information.