CONTENTS

 

SECTION 1

 

1. General standards that you can expect during a coroner's investigation

   

    1.1  The coroner’s office

   

    1.2  Your role

 

SECTION 2

 

2. Overview of coroners and investigations

 

     2.1  What is a coroner?

 

     2.2  What do coroners do?

 

     2.3  What is a coroner's investigation?

 

     2.4  What is a coroner's officer?

 

     2.5  Who pays for the local coroner service?

 

SECTION 3

 

3. Starting an investigation

 

     3.1  Are all deaths report to a coroner?

 

     3.2  When is a death reported to a coroner?

 

     3.3  What will a coroner do when a death is reported?

 

     3.4  Viewing the body

 

     3.5  When can a death be registered?

 

SECTION 4

 

4. The post-mortem examination

 

     4.1  What is a post-mortem examination?

 

SECTION 5

 

5. After a post-morten examination

 

     5.1  The post-mortem examination report

 

      5.2  What happens after the post-mortem examination?

 

SECTION 6

 

6. Release of the body for a funeral and adminstration of the estate

 

     6.1  What happens to the body after a post-mortem examination, if the coroner decides to continue the investigation? 

      

     6.2  What happens about administration of the deceased's estate if the coroner continues an investigation after a post-mortem examination?        

 

     6.3  What happens if I want to take a body abroad?

 

SECTION 7

 

7. Organs and tissues

 

    7.1  Will organs be retained after a coroner's post-mortem examination?

 

SECTION 8

 

8. The inquest

 

    8.1  What is an inquest?

 

    8.2  When will the inquest take place?

 

    8.3  Opening and adjourning an inquest

 

    8.4  What is a pre-inquest review?

 

    8.5  Who can attend an inquest?

 

    8.6  Will I need to speak at the inquest?

 

    8.7  Who decides which witnesses to call?

 

    8.8  Must a witness attend the inquest?

 

    8.9  Who can ask witnesses questions?

 

  8.10  Is there always a jury at an inquest?

 

  8.11  What does the jury do?

 

  8.12  Do I need a solicitor?

 

  8.13  Is legal aid available?

 

  8.14  Will the inquest be reported by the press?

 

SECTION 9

 

9. At the end of the inquest

 

    9.1  Inquest conclusions - determinations and findings

 

    9.2  What if future deaths may be prevented?

 

    9.3  Civil proceedings

 

SECTION 10

 

10. Investigations where the process may be different

 

  10.1  When an investigation is transferred to a different coroner

 

  10.2  A death abroad

  

  10.3  Deaths of service personnel overseas

 

  10.4  Death of a child

 

  10.5  When there is a criminal investigation into a death

 

  10.6  A death in prison or other state detention

 

SECTION 11

 

11. Feedback, challenging a coroner's decision and complaints

 

  11.1  Feedback

 

  11.2  How to challenge a coroner's decision or the outcome of an inquest

 

  11.3  Legal aid for challenges

 

  11.4  Complaints about a coroner's personal conduct

 

  11.5  Complaints about the standard of service received

 

  11.6  Complaints about a pathologist who conducts the post-mortem examination                     

 

SECTION 12

 

12. Monitoring coroner service standards

 

  12.1  Chief Coroner

 

SECTION 13

 

13. Getting more information and support

 

  13.1  How and when can I see the documents that are relevant to my loved one's death?    

 

  13.2  What about medical records?

 

  13.3  Where can I get further general information about coroner investigations?    

 

  13.4  What support can I get during an investigation?

 

  13.5  What about bereavement support?

 

SECTION 14

 

14. Glossary

 

SECTION 15

 

15. Your notes

 

 

 

 

 

 

 

     

 

 

 

 

 

 

SECTION 1

 

1. General standards that you can expect during a coroner's investigation

 

1.1  The coroner's office

 

The coroner's office will:

 

explain the role of the coroner and answer your questions about coroner investigations;

 

give you contact details for the office, i.e. a named individual and his or her phone number or email address;

 

help you understand the cause of death;

 

inform you of your rights and responsibilities;

 

take account where possible of your views and expectations, including family and community preferences, traditions and religious requirements relating to mourning, post-mortem examinations and funerals;

 

provide a welcoming and safe environment and treat you with fairness, respect and sensitivity;

 

act with compassion and without judgement about the deceased and the cause of death;

 

treat children and young people involved in an investigation in an age-appropriate way in co-operation with the adult(s) responsible for their care;

 

make reasonable adjustments, wherever possible, to accommodate your needs if you have a disability (including a learning disability);

 

help you to find further support where needed;

 

during a long investigation, unless otherwise agreed with you, contact you at least every three months to update you on the progress of the case, and explain reasons for any delays;

 

explain, where relevant, why the coroner intends to take no further action in a particular case.

 

The coroner's office cannot give any legal advice.

 

1.2  Your role

 

Your role in a coroner's investigation is very important and you have certain responsibilities. You should:

 

co-operate fully with the coroner's office and promptly provide all information that is relevant to the investigation;

 

inform the coroner's office of any concerns or worries you may have about the death;

 

treat the coroner and his or her officers and other staff with respect;

 

wherever possible nominate one individual as the 'next of kin' for communication with the coroner's office. This helps ensure prompt and accurate shaing of information;

 

inform the coroner's office of any change of circumstances, such as address or contact number, so you can be contacted promptly;

 

 

 

SECTION 2

 

2. Overview of coroners and investigations

 

2.1  What is a coroner?

 

A coroner is an independent judicial office holder, appointed by a local authority (council) within the coroner area. Some coroners cover more than one local authority. Coroners are usually lawyers but sometimes doctors. Coroners work within a framework of law passed by Parliament. The Chief Coroner heads the coroner service and gives guidance on standards and practice.

 

2.2  What do coroners do?

 

Coroners investigate deaths that have been reported to them if they have reason to think that:

 

the death was violent or unnatural;

 

the cause of death is unknown; or

 

the deceased died while in prison, police custody or another type of state detention such as an immigration centre or while detained under the Mental Health Act 1983.

 

when a death is reported to a coroner, he or she:

 

firstly establishes whether an investigation is required;

 

if yes, investigates to establish the identity of the person who has died; how, when, and where they died; and any information required to register the death; and

 

uses information discovered during the investigation to assist in the prevention of other deaths where possible.

 

2.3  What is a coroner's investigation?

 

The coroner's investigation is the process by which the coroner establishes who has died, and how, when, and where they died. The coroner may decide, as part of the investigation, to hold an inquest (see Section 8).

 

In some cases a death may be referred to the Police for investigation on behalf of the coroner. This may be because the Police have expertise, e.g. relating to a road traffic collision; or criminal activity may be relevant to the death.

 

In some cases other organisations such as a hospital, the Health and Safety Executive, the Prisons and Probation Ombudsman, the Care Quality Commission, are required to conduct a separate investigation into the death. This investigation usually takes place first and the coroner will be given the results so he or she can use the information in the inquest (see Section 8).

 

2.4  What is a coroner's officer?

 

Coroners' officers work under the direction of coroners and liaise with bereaved people as well as with the police, doctors, witnesses, mortuary staff, hospital bereavement staff and funeral directors. Most coroners' officers are civilians, but some are serving police officers.

 

Some coroners have staff with other titles such as a secretary or clerk.

 

2.5  Who pays for the local coroner service?

 

The costs of providing a local coroner's service is usually met by the local authority for that area. In some areas the local police force employs coroner's officers. However the officers' work is always carried out under the authority of the coroner who works independently from both the local authority and the local police force.

 

 

 

SECTION 3

 

3. Starting an Investigation

 

3.1  Are all deaths reported to a Coroner?

 

No, less than half of all deaths are reported to the coroner.

 

3.2  When is a death reported to a Coroner?

 

Registrars of births and deaths, doctors or the police must report deaths to a Coroner in certain circumstances. These include where it appears that:

 

no doctor saw the deceased during his or her last illness;

 

although a doctor attended the deceased during the last illness, the doctor is not able or available, for any reason, to certify the death;

 

the cause of death is 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 and unexplained;

 

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 another type of state detention (see Glossary).

 

If you believe that a death of this kind has not been reported to the Coroner, you may report it yourself. You should do this as soon as possible and before the funeral.  The Coroner will then inform you of the action he or she proposes to take.

 

The Coroner does not become involved in many cases when the deceased's own doctor, or a hospital doctor who has been treating him or her during the final stages of an illness, is able to diagnose and certify a natural cause of death.

 

3.3  What will a Coroner do when a death is reported?

 

A Coroner may conduct initial enquiries in order to decide whether to investigate the death. In some cases those enquiries, such as a discussion with the deceased's doctor, make it clear that the deceased died from a known and natural disease or condition and there are no unusual circumstances. The Coroner does not need to investigate further and the doctor will be asked to sign a Medical Certificate of the Cause of Death (MCCD). In these cases the Coroner will advise the register of births and deaths that, although he or she was made aware of the death, no further investigation is needed. The family can then make an appointment with the registrar to register the death.

 

However the Coroner may decide that he or she needs to ask a suitable practitioner, normally a pathologist, to examine the body and carry out a post-mortem examination to help find out the cause of death (see section 4 for more details).

 

3.4  Viewing the body

 

You, or a representative of your choice, may be asked to formally identify the body. You are also entitled to view the deceased should you wish to do so. The buildings where viewings take place vary in design and in some cases you will see the person through a glass window rather than being in the same room.

 

If, for example, the body has been damaged through involvement in a traffic collision, this will be explained to you with sensitivity and you will be given a choice as to whether you want to see the deceased or have some other form of identification used if possible.

 

3.5  When can a death be registered?

 

When the deceased's doctor, or a hospital doctor, certifies the cause of death without referring it to a Coroner, the death can be registered by the registrar of births and deaths, who issues the death certificate. 

 

Sometimes a doctor may discuss the case with the Coroner. This may result in the Coroner deciding that he or she does not need to investigate, because the death is from natural causes. In light of that discussion, the doctor concerned may be able to issue the MCCD and the Coroner will issue a certificate to the registrar stating that it is not necessary for the Coroner to investigate the death.

 

If the Coroner decides to investigate the death, the registrar of births and deaths must wait for the Coroner to finish the investigation before the death can be registered. This investigation may take time, for instance if there is to be an inquest (see section 8), so it is always best to contact the Coroner's office before any funeral arrangements are made. In most cases the decision to investigate will not hold up funeral arrangements or sorting out benefits.

 

The Coroner may issue a certificate, confirming the fact of death and where known, the medical cause of death. Although this cannot be used to register the death, it may be used to assist in the administration of the estate (see section 6 for more details on this).

 

Standards of service you can expect when a death is investigated by a Coroner

 

Whe a death is investigated by a Coroner, the coroner's office will contact the next of kin, where known, and where possible, within one working day of the death being reported, to explain why the death has been reported and what actions are likely to follow.

 

 

SECTION 4

 

4. The post-mortem examination

 

4.1  What is a post-mortem examination?

 

A post-mortem examination is a medical examination of a body after death to find out the cause of death. A Coroner's post-mortem examination is independent and is carried out by a suitable medical practitioner such as a pathologist (a doctor who specialises in medical diagnosis by examining body organs, tissues and fluids) of the Coroner's choice.

 

The Coroner decides whether or not a post-mortem examination is needed and what type of examination is most appropriate.  By law, the Coroner is not required to obtain your consent to the examination, but he or she will give you the reason for his or her decision (which will be one or more of the factors set out in 3.2).

 

Usually a post-mortem examination involves opening and examining the body internally. In some parts of the country other techniques such as CT (computerised tomography) scanning or MRI (magnetic resonance imaging) are available and may be preferred by people who have a strong objection to an invasive examination of the body. It is the Coroner who will decide if a scanning technique is appropriate (if available), depending on the circumstances of the death. Where a scanning technique is used, the family or the next of kin will be required to pay a fee (for this and for any additional tests that the Coroner decides are needed). The use of a scanning technique may not avoid the need for a full post-mortem examination if the scan does not identify the cause of death.

 

Where possible, Coroners will take account of your religious and cultural needs whilst acting in accordance with the law when ordering a post-mortem examination and the type of examination to be performed.

 

You can be represented by a doctor of your choice at the examination, although this is not normally necessary (and you would have to pay any fee the doctor may charge). If you choose to be represented you should advise the Coroner straight away. The Coroner's office will tell you when and where the examination will happen.

 

Sometimes the Coroner will request a 'forensic post-mortem examination' (for example, in a case of suspected murder) or additional scientific examination of material to assist with establishing the cause of death or, rarely, the identity of the deceased.

 

If you remain concerned about the cause  of death, you can arrange for a separate, additional post-mortem examination. This would be at your own expense, once the Coroner has released the body.

 

Standards of service you can expect regarding a post-mortem examination

 

Whenever possible the Coroner's office will, on request, tell you when and where an examination will be performed.

 

If you have queries, or object to the decision to hold a post-mortem examination or carry out addition examination of tissue, you should let the Coroner's office know as soon as possible so your wishes can be considered.

 

If the Coroner decides not to request a post-mortem examination, and you think there should be one, you should discuss this with the Coroner's office.

 

In all cases the final decision about a post-mortem examination and any other tests is the responsibility of the Coroner.

 

 

SECTION 5

 

5. After a post-mortem examination

 

5.1  The post-mortem examination report

 

After the post-mortem examination the pathologist will send a report to the Coroner. The report will give details of the examination, of any tissues and organs retained, and any tests, such as for drugs and blood alcohol level, which have been carried out to help in finding the cause of death.

 

Sometimes the pathologist's report may not be available for several weeks because of the complexity of the examination (especially if there has been a forensic examination, organs need very special examination, or the examination has been carried out on an infant).

 

You may ask for a copy of the pathologist's report.

 

5.2  What happens after the post-mortem examination?

 

A Coroner may decide the investigation is either unnecessary or complete if the post-mortem examination has shown the cause of death. The Coroner will then release the body so that the funeral can take place.

 

The Coroner will send a form to the registrar of births and deaths stating the cause of death as shown by the post-mortem examination report. When the registrar has received this form you can make an appointment to register the death.

 

Sometimes a Coroner may decide that further investigation is needed into the death. The Coroner will still usually release the body at this point so the funeral can take place if he or she no longer needs the body for investigation. However occasionally this is not possible and, if so, the Coroner's office will explain the arrangements to you.

 

Occasionally, while the Coroner can release a body for funeral purposes, it may not be possible to release a particular organ (or organs) immediately because a specialist and lengthy examination is required. Again the Coroner's office will advise you of the various options available to you.

 

You may wish to find a funeral director through one of the industry's trade associations, the National Association of Funeral Directors (NAFD) (http://www.nafd.org.uk/funeral-advice/funeral-advice-home.aspx) or the National Society of Allied and Independent Funeral Directors (SAIF) (https://www.saif.org.uk/website/index.html).

 

 

SECTION 6

 

6.  Release of the body for a funeral and administration of the estate

 

6.1  What happens to the body after the post-mortem examination, if the Coroner        decides to continue the investigation?

 

By law a Coroner must continue an investigation and hold an inquest if:

 

the cause of death remains unknown after the post-mortem examination and any subsequent tests;

 

there is cause for the Coroner to suspect that the deceased died a violent or unnatural death; or

 

the death occurred in custody or state detention.

 

The Coroner must release the body for burial or cremation as soon as possible. If the Coroner cannot release the body within 28 days then he or she must notify the know next of kin or personal representative of the reasons for the delay. (An example might be if there is a dispute about to whom the body should be released.)

 

Procedures may vary where there is a criminal investigation into the death.

 

6.2  What happens about administration of the deceased's estate if the Coroner continues an investigation after a post-mortem examination?

 

In order to assist with the administration of the estate, if a Coroner has begun but not yet completed or discontinued an investigation the Coroner may issue a Coroner's certificate of the fact of death.  This certificate should be acceptable to banks and financial institutions unless it is important for them to know the outcome of the investigation (for example, for an insurance settlement). A grant of probate or letters of administration can be obtained using a certificate of the fact of death and it can also be used for benefit claims and National Insurance purposes.  However, the certificate of the fact of death cannot be used to register the death, even if the medical cause of death is known.

 

The Government's Tell Us Once Service is available in most areas of England and the whole of Wales.  After the death has been registered Tell Us Once lets you report it to most of the government organisations you need to tell in one go.  The Tell Us Once Service can also be offered where the Coroner has issued a certificate of the fact of death.  The service can be accessed face-to-face at your local council, online (https://www.gov.uk/tell-us-once) or over the phone (the registrar of births and deaths will be able to give you the relevant phone number).

 

When the Coroner's investigation (including the inquest if one is to be held) has been completed the Coroner will notify the registrar of births and deaths so that the death can be registered by the registrar and a death certificate can then be purchased from the registrar.

 

6.3  What happens if I want to take a body abroad?

 

The Coroner has to be notified if a body is to be taken out of England and Wales.

 

If you intend to do this, you must give the Coroner written notice as soon as possible.  The Coroner will then consider whether any (further) investigation is needed and will notify the next of kin of his or her decision as soon as possible and within four days.  Most funeral directors can give further information on this procedure and the registrar can give you the necessary form when you register the death.

 

 

SECTION 7

 

7.  Organs and tissue

 

7.1  Will organs be retained after a Coroner's post-mortem examination?

 

Small pieces of tissue and, occasionally, organs may be removed from a body and preserved by a pathologist if they are relevant to the cause of death or the identity of the deceased.  If this material is retained for additional examination, the Coroner will notify the next of kin, and ask what they wish to happen to the organs or tissue when no longer required.

 

When the material is no longer needed for the Coroner's investigation it will either be kept as part of the pathology record or returned to the deceased's family or representative, if requested, or disposed of by burial or cremation.  If a pathologist believes it would be appropriate to keep organs and tissue, for example for use in research or for training purposes, he or she must obtain your consent.  In exceptional cases, e.g. involving murder, the retained tissue may have to be kept for a longer period.

 

Further general information on tissue retention and the legal requirements relating to consent can be obtained from the Human Tissue Authority on 020 7269 1900 or online at http://www.hta.gov.uk.

 

 

SECTION 8

 

8. The Inquest

 

8.1  What is an inquest?

 

If it was not possible to find out the cause of death from the post-mortem examination, or the death is found to be unnatural (or occurred in state detention) or the Coroner thinks there is a good reason to continue the investigation a Coroner has to hold an inquest to be able to finish his or her investigation.  (The exception is if someone is to be prosecuted for causing the death - there is more information about this in section 10.)