The Coroner

What is the role of the coroner?

A coroner enquires into those deaths reported to him. It is his duty to find out the medical cause of the death, if it is not known, and to enquire about the cause of it if it was due to violence or was otherwise unnatural.

Who are coroners?

Coroners are usually lawyers but in some cases they may be doctors. Coroners are independent judicial officers - this means that no-one else can tell them or direct them as to what they should do but they must follow the laws and regulations which apply.

Each coroner has to have a deputy and between them they have to be available at all times. Her Majesty's Coroner for the City of Plymouth and South West Devon is Mr Ian Arrow. Coroners are governed by the Coroner's Act 1988, Coroner's Act 1984 and Coroner's Rules (Amendment) 2005. In Britain there are 110 coroners with 90% being lawyers. Only 30 of these are full time.

Coroners are helped by their officers, who receive the reports of deaths and make enquiries on behalf of the coroner. Some officers are full-time but in quieter parts of the country they are part-time and often work as policemen or policewomen the rest of the time. The cost of the coroners' service is met by local taxation.

The coroner is responsible for investigating deaths in the following situations (these are purely examples, see the documents table below for a more detailed guide).

• the deceased was not attended by a doctor during the last illness or the doctor treating the deceased had not seen him or her either after death or within the 14 days before death or in the circumstances set out in Regulation 41 of the Births Deaths Regulations 1987 (No.2028)
• the death was violent or unnatural or occurred under suspicious circumstances
• the cause of death is not known or is uncertain
• the death occurred while the patient was undergoing an operation or did not recover from the anaesthetic
• the death was caused by an industrial disease
• the death occurred in prison or in police custody

If you want advice or information about a death which has been reported to the coroner, contact the coroner’s office.

Reporting a death to the coroner

There is a common law duty on all citizens including doctors to report the facts and circumstances to the coroner which may lead him to open an inquest and in particular the following (by way of example only):

• an accident or injury
• an industrial disease
• during a surgical operation
• before recovery from an anaesthetic
• if the cause of death is unknown
• the death was sudden and unexplained, for instance, a sudden infant death (cot death).

The coroner may be the only person who can certify the cause of death. The doctor will write on the Formal Notice that the death has been referred to the coroner. If the doctor treating the deceased had not seen him or her, either after death or within 14 days before death, the death must be reported to the coroner.

What will the coroner do?

The coroner may decide that death was quite natural and that there is a doctor who can sign a form saying so. In this case the coroner will advise the registrar.

The coroner may ask a pathologist to examine the body. If so, the examination must be done as soon as possible. The coroner or his staff will, unless it is impracticable or cause undue delay, give notice of the arrangements to, amongst others, the usual doctor of the deceased, and any relative who may have notified the coroner of his or her wish to be medically represented at the examination.

If the examination shows the death to have been a natural one, there may be no need for an inquest and the coroner will send a form to the registrar of deaths so that the death can be registered by the relatives and a certificate of burial issued by the registrar. If the person is to be cremated, the certificate may be issued by the coroner.

Documents

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	Coroner's charter - this charter tells you what standards of performance are to be expected in the coroner service and what to do if something goes wrong. File format Adobe Acrobat (pdf) - 74.5KB
	Reporting deaths - guidance notes for reporting deaths to the coroner and death certification. File format Adobe Acrobat (pdf) - 19.5KB
	Retention of human tissue and organs - guidance notes for next of kin and executors relating to coroner’s post mortem examinations and the retention of human tissue and organs. File format Adobe Acrobat (pdf) - 24KB
	Foetal deaths, still births and neo-natal death - guidance notes for the reporting and/or the certification or otherwise of foetal deaths, still births and neo-natal death. File format Adobe Acrobat (pdf) - 16.5KB

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