Coroner's Investigations:
Brief Overview
Below is a brief overview of the role and purpose of an investigation by His Majesty's Coroner. For more information please see the below download:
Who is involved in the coroner process and what is my role?
HM Coroner is a special judge who investigates unnatural or violent deaths, where the cause of death is unknown, or because the death took place in prison, police custody or resulted from an injury caused by a police officer in the purported execution of his duty.
The investigation may include an inquest hearing.
HM Corner’s role is to find out who died and how, when, and where they died. They cannot make a finding that someone is guilty of something or to blame for something.
As a relative or representative of the person who died you have the right to receive documents and evidence and to ask the witnesses relevant questions at the inquest hearing.
Your main contact with HM Coroner will be through the Coroner’s office who will answer any questions you may have and keep you informed of progress.
Starting the Investigation – what will HM Coroner do?
A death may be reported to HM Coroner by different people, such as the police, prison officers, the registrar of births and deaths, doctors or a hospital.
When a death is reported, HM Coroner first carries out enquiries to see if they can find the cause of death quickly. If they can, and the death was due to natural causes, in most cases HM Coroner has no further role.
If the cause of death is still not known or appears unnatural or violent, HM Coroner investigates to find out the cause of death. This may include a post-mortem.
If the cause of death is unknown or the death was violent or unnatural, HM Coroner needs to hold an inquest. Sometimes, HM Coroner may need to hold an inquest even if the death was natural and the cause is known. This will happen when the person died in prison.
HM Coroner will usually let you have the body for burial or cremation once they have carried out their first enquiries. You can make funeral arrangements once this has happened.
You cannot register the death (a legal requirement to tell the government that a person has died) until the cause of death is known. However, HM Coroner can give you an ‘interim certificate of the fact of death’ to help you deal with administrative matters. This is also sometimes called an interim death certificate.
HM Coroner has asked for a post-mortem – what is going to happen?
A post-mortem is a medical examination of the body after death in order to find out the cause of death.
Usually the post-mortem involves operating on the body to carry out an internal examination. Sometimes there can be a scan of the body instead.
You cannot attend the post-mortem yourself, but you can ask a doctor to attend for you – although the doctor may charge you for this.
The specialist doctor who conducts the post-mortem will write a report for HM Coroner. You can ask the Coroner’s office for a copy.
Sometimes samples of blood or body tissue including organs will be kept after the body has been released if further tests and investigations are needed to determine the cause of death. You will be given options to decide what happens to the tissue that has been taken.
There is going to be an inquest – will I need a lawyer?
You do not need to have a lawyer to attend or participate in an inquest.
HM Coroner will help you understand what is happening at the inquest and why.
You may want to consider getting legal help for an inquest hearing if other interested persons are represented, for example if the state or a public body has legal representation at the inquest.
Depending on your financial circumstances, you may have a right to financial support from the government to pay for legal help to prepare for the inquest; or legal representation at the inquest.
Public funding (‘legal aid’) to have a lawyer represent you at an inquest hearing is only available in certain circumstances.
An inquest is going to be held – what happens next?
An inquest is a public court hearing for HM Coroner, sometimes with a jury, to decide who died, how, when and where the death happened.
In more complex cases or where there are many witnesses, there may be a pre-inquest review where HM Coroner sets out how the inquest will run, the main issues that will be considered, the documents that will be needed, what evidence will be heard, and what witnesses and experts will be called.
You may be asked to give evidence if you can give information about the death. You can still attend the inquest if you are not giving evidence.
You, or your legal representative where you have one, can ask the witnesses relevant questions. HM Coroner can help you with this and can ask the questions on your behalf.
A friend or family member can sit with you during the hearing to give you support.
There has to be a jury in some circumstances as set out in the Act, such as where the death happened in prison.
At the end of the inquest?
When HM Coroner has heard all the evidence, they will give a summary of the main points.
You or your legal representative (if you have one) cannot address HM Coroner on the facts of the case.
If you have a legal representative, they have a right to address HM Coroner on what the law says on possible conclusions HM Coroner or jury could make.
HM Coroner, or the jury if there is one, will then give their conclusion on who died, how, when and where the death happened.
Circumstances in which the inquest process may be different
There are some circumstances when the process may be different. These include:
- where the person died in prison, police custody or died as a result of an injury caused by a police officer in the purported execution of his duty,
- Where there is a criminal investigation.
- Where there is another investigation such as a public inquiry investigating the death.