Coroner's Investigations: A practical guide

Please be aware that in most legal situations a person who has died is referred to as the deceased. This convention has been used in this guidance. Coroner's and their staff understand that the person who has died was a unique individual.

What is a coroner and what do they do?

A coroner is an independent judicial office holder. The coroner for the Falkland Islands is also the Senior Magistrate.

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

· The death was sudden, violent or unnatural

· The cause of death is unknown

· The deceased died while in prison or police custody

In these cases coroners must investigate to find out, for the benefit of the bereaved people and for official records, who has died and how, when and where they died.

When a death is reported to the coroner, he or she:

· Firstly establishes whether an investigation is required;

· If yes, investigates to establish the identity of the deceased, how, when and where they died and any information required to register the death; and

· Uses information discovered during the investigation to assist in preventing other deaths where possible.

What is a coroner's officer?

Coroner's officers work under the direction of the coroner and liaise with bereaved people as well as with the police, doctors, witnesses and hospital staff.

What will the coroner do when a death is reported?

A coroner may conduct initial enquiries to decide whether the death should be investigated. In some cases those enquiries, such as a discussion with the deceased's doctor, make it clear that the deceased died from a known or natural cause and there are no unusual circumstances. The coroner does not need to investigate further and will advise the Registrar of Births and Deaths that no further investigation is needed and you will be able to register the death.

However, the coroner may decide that he or she needs to ask a suitable medical practitioner to examine the body and carry out a post-mortem examination to help find out the cause of death.

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 is independent and is carried out by a specialist medical practitioner.

The coroner decides whether or not a post-mortem examination is necessary and what type of examination is most appropriate. By law, the coroner is not required to obtain your consent to the examination, but you will be informed.

If the coroner decides that an investigation is necessary, a pathologist will normally carry out a post-mortem examination of the body.

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 the fee any doctor may charge). If you choose to be represented you must tell the coroner straight away. The coroner will inform you of when and where the examination will happen.

If the post-mortem shows a natural cause of death, the coroner will send a form to the Registrar of Births and Deaths stating the cause of death. You will be informed and can then make an appointment to register the death.

Release of the body

Once a death has been reported to the coroner, the body comes under the coroner's control. The coroner will issue an order releasing the body for a funeral as soon as possible but this will not be done until all required medical examinations have been completed. The body can usually be released before the coroner receives the results of any body tissue tests. The release order will be sent directly to the hospital and the Public Works Department so that funeral arrangements can be made.

You should let the coroner know in writing if you wish to take the body out of the Falkland Islands. There is a form that you can obtain from the court staff to seek the coroner's permission to do this.

Viewing the body

If you wish to visit the deceased you may make a request to do so via the coroner's officer or directly with the hospital. The coroner must authorise any visits before any arrangements can be made with you. If you are not allowed to view the body you will be informed of this as soon as possible and you will be given reasons why the visit has been refused or told if there are to be any restrictions when you visit.


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, the coroner has to hold an inquest. An inquest is a public court hearing held by the coroner in order to establish who died and how, when and where the death occurred.

An inquest is different from other types of court hearing because it is a fact finding process and there is no prosecution or defence. The purpose of the inquest is to discover the facts about the death. This means that the coroner cannot find a person or organisation criminally responsible for the death.

The inquest will be held as soon as possible and ordinarily within 3 months of the death being reported. The coroner will let you know if more time is needed and what to expect in your case.

Who can attend an inquest?

Inquest hearings are almost always held in public. The next of kin are by law interested persons and will therefore be informed of the details of any hearings in advance.

If you choose to attend the inquest you can be accompanied by a supporter, for example a friend. Some bereaved people prefer not to attend, as the details of the death may be distressing.

Witnesses may be asked to attend to give evidence. Members of the public and media are normally allowed to attend the inquest.

Opening the inquest

Where an inquest is required the coroner must open the inquest as soon as possible. This is usually done within 7 days of the report of the death to the coroner. This "opening" of the inquest is typically very brief but is usually held in public. The coroner will then immediately adjourn the inquest until a later date by when he or she will have the information required to complete the inquest. At the opening of the inquest the coroner will where possible set the dates for subsequent hearings.

Pre-inquest hearing

Sometimes the coroner may hold one or more hearings before concluding the inquest. The coroner will invite you to any pre-inquest hearings.

It is not necessary for you to attend the opening of the inquest but you may if you wish to do so.

At the end of the inquest

The coroner comes to a conclusion at the end of an inquest. This includes the legal determination, which makes findings in relation to the questions about who died, when they died and where and how they died. The coroner also makes findings to allow the cause of death to be registered. When recording the cause of death the coroner may use one of the following terms:

· Accident or misadventure

· Unlawful killing

· Natural causes

· Open

· Road traffic collision

· Suicide

The coroner may also make a brief narrative statement setting out the facts surrounding the death in more detail and explaining the reasons for the conclusion.

After the inquest has concluded the coroner will inform the Registrar of Births and Deaths of the outcome and arrange for the death to be registered.

Do I need a solicitor?

In most cases instructing a legal practitioner to represent you is not necessary, but you may do so if you wish. An inquest is a fact-finding process and the coroner will ensure that the process if fair and thorough, and that your questions about the facts of the death are answered.

It is important that you tell the coroner if you will have a legal practitioner present, so that the coroner knows they are there at your request and with your consent. Your legal practitioner may also attend any pre-inquest review.

Is legal aid available?

Interested persons may be entitled to legal aid under the Legal Aid Ordinance 2020. To find out if you qualify for legal aid please consult a legal practitioner or view the legislation here.

More information

This guidance is a brief summary and does not cover every circumstance. Please ask the coroner's officer or court staff as many questions as you need.