The role of the Coroner is to record and investigate all deaths which are

• sudden
• unexpected
• violent
• in lawful custody

or which might come into these categories.

There are other occasions when a death will be reported to the coroner, e.g. when no doctor has treated the deceased during his or her last illness.

Coroners are usually lawyers but in some cases they may be doctors.

Deaths are usually reported to the coroner by the police or by a doctor called to the death if it is sudden.

A doctor will also report a patient's death if it is unexpected.

In other cases, the local registrar of deaths may make the report.

Whenever the death has been reported to the coroner the registrar must wait for the coroner to finish his or her enquiries before the death can be registered.

What happens when a death is reported to the Coroner?

The Coroner may order a post-mortem examination to disover the cause of death.

The Coroner may also hold an inquest, which is an investigation into the circumstances leading up to the death.

What is the function of an inquest?

The function of an inquest is to record

• who the deceased was
• when, where and how he or she came by the medical cause of death.

An inquest is not a trial. It is a limited inquiry into the facts surrounding a death.

It is not the job of the coroner to blame anyone for the death, as a trial would do.

It is not the function of an inquest to determine any question of civil liability or criminal liability on the part of a named person.

The inquest is an inquiry to find out who has died, and how, when and where they died, together with information needed by the registrar of deaths, so that the death can be registered.

All inquests must be held in public and someone from the press is usually present in court. The inquest tries to get at the truth, and can often help to stop the spread of untrue stories about the death. Suicide notes and personal letters will not be read out unless they have to be.

A conclusion is reached and the Coroner records the details needed for the registration of the death.

Useful resources

Detailed explanation and useful links to reports and guidance. (external link)

Coroner’s Inquest: your rights: Liberty guide (external link)

The Rights of the Bereaved: Liberty guide (external link)

Model coroner's service charter (external link)

Kings College Fund Guide to the coroner still to come