Coroners – Why is the Coroner Involved?

Coroners are called in to investigate over 4 in 10 deaths. The reason is often as simple as you haven’t been seen by your  own doctor for more than 2 weeks, or the death is unexpected. Very rarely is there anything to worry about, but their work can help improve medical knowledge. Coroners are independent judicial office holders who must be a lawyer or a doctor, and in some cases is both. They are employed by Local Authorities and cover that council’s area. Each one has a deputy and usually one or more assistant deputies, as a coroner must be available 24 x 7. In 2018, 41% of deaths were referred to the coroner, so it is not at all unusual. If you want to go into their function in way more detail, download the full Guide to the Coroner Service here.

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What do coroners do?

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Coroners inquire into nearly half of all deaths, for example, those that are unexpected, violent or unnatural deaths, sudden deaths of unknown cause, and deaths which have occurred in prison. The reason may be as simple as the attending doctor being on holiday and therefore being unable to explain the death in person. A coroner’s authority to inquire is based on the location of the body, not from where the death occurred.

The coroner, when a death is reported to him will:

  • decide if an inquest is required;
  • if so, confirm the identity of the deceased, and how, when, and where they died;
  • try to help to prevent further deaths with similar caused; and
  • try to reassure the public.

After an inquest, the necessary details are sent by the coroner to the Registrar of Births and Deaths so that the death can be registered (if it occurred in England and Wales.)

In some cases, a death may be referred to the police. There may be an investigation by a body like the Health and Safety Executive, the Prisons and Probation Ombudsman, the Care Quality Commission or the Independent Police Complaints Commission. The coroner will be given the results of the investigation.

What is a coroner’s officer?

Coroners’ officers work for coroners and liaise with bereaved families, the police, doctors, witnesses,  mortuary staff, hospital bereavement staff and funeral directors. They receive reports of deaths and make inquiries on behalf of the coroner

Are all deaths reported to a coroner?

Under half of all deaths are referred to them. Mostly, the deceased’s own GP, or a hospital doctor who has been treating them during their final illness, can issue a Medical Certificate of the Cause of Death (MCCD.) The death can then be registered by the Registrar of Births and Deaths, who will issue the death certificate. Doctors may discuss marginal cases with the coroner and often the GP will then be able to issue the MCCD and the coroner issue a certificate to the Registrar confirming that an inquest is unnecessary.

Should the coroner decide to inquire into a death the Registrar of Births and Deaths has to wait for the coroners’ clearance before the death can be registered. The inquiries may take some time, so discuss matters with the coroner’s office before making any funeral arrangements.

When is a death reported to a coroner?

Registrars of Births and Deaths, doctors or the police report deaths to a coroner. Circumstances where it appears that:

  • No doctor attended the deceased during his or her last illness.
  • Although a doctor attended during the last illness the deceased was not seen either within fourteen days before death nor after death.
  • The cause of death appears to be unknown.
  • The death occurred during an operation or before recovery from the effects of an anaesthetic.
  • The death occurred at work or was due to industrial disease or poisoning.
  • The death was sudden or unexpected.
  • The death was unnatural.
  • The death was due to violence or neglect.
  • The death was in other suspicious circumstances. Or
  • The death occurred in prison, police custody or other state detention.

Whilst reports to the coroner usually come from professionals, anyone with good cause may report the death to the coroner. Obviously, this should preferably happen before there has been any interference with the body and before a funeral takes place. The coroner will tell the informant what action the coroner intends to take when reports are made in this way.

What will a coroner do when a death is reported?

The coroner may ask a pathologist to carry out a post-mortem examination (same as an autopsy). Or the coroner may consider that unnecessary as the cause of death is evident and natural and there is a doctor who can sign an MCCD to that effect. The coroner will then confirm to the Registrar of Births and Deaths that further investigation is not required.

What is a post-mortem examination?

It’s a medical examination of a body carried out for the coroner by a pathologist, a specialist doctor to establish the cause of death.

The consent of relatives is not required for a post-mortem, but the coroner is required to inform the deceased’s relatives and GP of when and where the examination will take place, provided they have previously advised the coroner that they would like to be present or represented. They can be represented by a doctor of their choice, at their own expense. Coroners will take account of religious and cultural needs where practicable. Relatives can have a separate autopsy at their own expense when the coroner has released the body should they wish to.

Post-mortem examination report.

The post-mortem report details the examination of the body and is sent to the coroner by the pathologist. It will also give details of tissues and organs removed from the deceased, and any tests, such as for drugs and blood alcohol level, which have been carried out to assist in unveiling the cause of death. Copies are normally available only to properly interested persons.

The coroner may decide an inquest is not required after a post-mortem if there is no reason to think the person died a violent or unnatural death and did not die in prison. The coroner would then release the body and send a form to the Registrar of Births and Deaths stating the cause of death as reported in the post-mortem report so that the death can then be registered and funeral authorised. This is provided that the coroner considers that no further inquiries are necessary.

Medical records

Medical records remain confidential but may be shown to the deceased’s personal representatives or anyone who may have a claim arising from the death, subject to some restrictions, under the terms of the Access to Health Records Act 1990 see

Coroners are entitled to medical information that is relevant and necessary to their inquiries. Medical information about the deceased may be disclosed at the inquest if it is relevant.

Will organs be retained after a coroner’s post-mortem?

Organs and, more commonly, small pieces of tissue may sometimes be removed and preserved if they have any bearing on the cause of death or the identity of the deceased. When the material no longer needed it will either be returned to the deceased’s family, if requested or disposed of by burial or cremation. If a pathologist wishes to retain organs and tissue, perhaps for use in research or for training purposes, the consent of the relatives is required. In exceptional cases, e.g. involving murder, the organs may have to be retained for a longer period. See also

What happens after the post-mortem if the coroner decides to hold an inquest?

A coroner must hold an inquest if the cause of death remains unknown after the initial post-mortem examination and subsequent tests, or if there is cause for the coroner to suspect that the deceased died a violent or unnatural death, or died in prison. However, after the post-mortem examination, the coroner will usually give authority for the funeral, even though an inquest may be required but has not been concluded.

In such circumstances, the death cannot be registered. An interim certificate of the fact of death can be issued by the coroner. This certificate should be acceptable to banks and financial institutions unless it is important for them to know the outcome of the inquest (for example, for an insurance settlement). This interim certificate can be used for benefit claims and National Insurance purposes.

When the inquest has been completed the coroner will advise the Registrar of Births and Deaths so that the death can be registered and a death certificate issued.

If criminal charges have been brought against somebody for causing the death, it may be necessary for a second post-mortem examination to take place or for further investigation, and the release of the body and the funeral arrangements may then have to be delayed.

Taking the body abroad or bringing it back to this country.

Always when a body out is to be taken out of England or Wales, written notice must be given to the coroner in whose area the body is located. The coroner will then consider whether an inquest or post-mortem examination is needed and will notify the next of kin of his or her decision within four days.

If a body is being brought into England or Wales, the coroner in the area to where the body is brought may need to be involved. The coroner may need to determine the cause of death and will be required to hold an inquest if the death was unnatural, or violent, or sudden and of unknown cause. The coroner will issue a certificate for cremation in all cases coming from abroad where the body is to be cremated.

When death has occurred outside England and Wales and the body is returned to England or Wales, the death is not registered by the Registrar of Births and Deaths when the coroner has finished investigating or has concluded the inquest. Further information about what to do when a death occurs abroad can be found on the Foreign and Commonwealth Office’s website, at:

If cremation takes place abroad and the cremated remains are brought back into England or Wales, they will not have jurisdiction and therefore an inquest cannot take place.

They may conduct or order an inquest into the manner or cause of death, and investigate or confirm the identity of an unknown person who has been found dead within the coroner’s jurisdiction.

In medieval times, they were Crown officials who held financial powers and conducted some judicial investigations in order to counterbalance the power of sheriffs.

The word derives from the same source as the word crown, and it is believed to denote an officer of the Crown.

Information on Coroners Inquests.

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