The Coroner

If you,  your friends, or family have lost a loved one through murder or manslaughter ("homicide") abroad, you will need a good understanding of how the British Coroner system works.

First and foremost, you should realise that unless the body of the deceased is repatriated to the UK, and not buried or cremated in the country of the death, the British Coroner will not be able to investigate the death.

The Coroner’s role is purely inquisitive - it is not judgemental, it has nothing to do with blame. However the Coroner’s job is very much in line with the objectives of most victim’s families, and that is to find out the truth surrounding the death. So it is best to establish a good working relationship with the Coroner and his or her staff. 

The Coroner system is confined to the UK, America, and some previously Commonwealth countries. There is no equivalent system in Europe, or elsewhere in the world. It is a very complex area of UK Law, and is actually slightly different in different parts of the UK. So this is a brief layman’s guide to the Coroner system in England & Wales (for information relating to Scotland, we recommend contacting DAYNA - a support group for families, partners and friends of Scottish citizens who have died abroad from natural circumstances, accidental death, suspicious circumstances or murder). 

What is the role of the Coroner in England & Wales?
The Coroner is a person employed by the Local Authority primarily to investigate unexpected, unexplained, and violent deaths. Their job is to determine who the person was, and when, where, and how they died. The Coroner has extensive investigative powers to assist them in this task. They can interrogate witnesses, police, doctors,  hospital staff and anyone else that may have relevant information. 

The Coroner is not able to apportion blame , or civil, or criminal,  liability for the death, and the Coroner’s verdict must not be “inconsistent” with the verdict reached by a prior criminal prosecution of an alleged perpetrator. It is for this reason that Coroner’s Inquests are often opened, and then immediately adjourned until after Criminal proceedings, here, or overseas, have taken place. 

Map from Coroners Statistics Annual 2015 England and Wales Ministry of Justice Statistics bulletin Published 12 May 2016 © Crown copyright

Map from Coroners Statistics Annual 2015 England and Wales Ministry of Justice Statistics bulletin Published 12 May 2016 © Crown copyright

How do I find my local Coroner?
The names, addresses and jurisdictions of coroners can be found at  As the name of this website suggests, the Coroner has a second, less well known, investigative job, and that is to examine and determine the likely ownership of discovered buried treasure, or “finds”. 

There are 109 Coroner’s “jurisdictions”, or defined areas of the country, broadly in line with County and Metropolitan local authorities. Each will have at least one Coroner, and Assistant Coroner, and if the population density requires it, more than one .

What training and support do Coroners have?
Coroners are specially trained and almost always have a legal background, such as being a solicitor, or barrister, although sometimes they may come from a medical background, and they must have had at least 5 years in their profession. They have staff and Coroner’s Officers, who are usually from a Police background. They often have their own courtroom. They are typically paid around £100k per annum. Interestingly, although they report to the Lord Chief Justice (via the Chief Coroner), they and their costs, are paid by the Local Authority. 

The Coroner and Justice Act 2009 was implemented on 25 July 2013, and under this Act, amongst other things, a new position of Chief Coroner was created. The Chief Coroner will have been a High Court Judge, and has the job of monitoring the service with a view to improving it, and has to prepare annual reports for Parliament. The Lord Chief Justice, after consultation with the Lord Chancellor,  appointed His Honour Judge Mark Lucraft QC as the Chief Coroner of England and Wales with effect from 1 October 2016 for a three-year term, replacing His Honour Judge Peter Thornton QC who retired as Chief Coroner on 30th September 2016.

The Coroner's role in death overseas
Around 4,000 British nationals die overseas each year. Around 100 of these are definite homicides ( ¼ %). There will also be “suspicious deaths”, accidents, and many initially “unexplained” deaths, as well as natural causes. In the UK more than half a million people die each year, and around 230,000 of these deaths are reported to the Coroner, and approximately 500 of these are definite homicides (0.1%). 

A Coroner has the duty to investigate if:
1)    the coroner is made aware that the body is within that coroner’s area, and
2)   the coroner has reason to suspect that:
      a)  the deceased died a violent or unnatural death;
      b) the cause of the death is unknown; or
      c) the deceased died while in custody or state detention. 

The coroner must then establish who has died and how, when, and where they died. Not every Coroner’s enquiry leads to a formal inquest - often a Coroner is able to establish the necessary facts from his own early enquiries. Frequently an inquest will be opened, and then immediately adjourned to give the Coroner time to gather all the necessary evidence, and time to allow criminal proceedings (if any) to take place. 

Coroners are encouraged to undertake the investigation alone (without a jury) although they can chose to have a jury, and in some cases must have a jury, typically when a death has occurred whilst the person was in state custody (police, prison, or military). Other cases that warrant the use of a jury are when the person has died from work-related causes, or when there is reason to believe that similar future deaths may arise from the same cause, and the Coroner can then sometimes make recommendations to prevent similar occurrences. 

When it is necessary for essential documents, written in a foreign language, to be used in evidence, the Coroner will have translations made, at the cost of the Local Authority. 

Repatriation of the body of a person who has died abroad is the only way that a UK Coroner’s investigation can be initiated. If the body is not repatriated, there will be no investigation. 

When a body is repatriated, generally by air, it  technically becomes within the jurisdiction of the Coroner for the landing place, although most usually, this responsibility is transferred to the Coroner whose jurisdiction includes the place where the deceased, or their immediate family normally live. This is for the convenience of the family. 

Post-mortem examination
The first step for the Coroner is to order a post-mortem examination, by a pathologist. 

Once the post-mortem examination (including any histology or toxicology) has concluded, the coroner must decide how to proceed. There are three main options: 

  • If the post-mortem examination reveals that the deceased died of natural causes and the coroner thinks that it is not necessary to (investigate or) continue the investigation, then there will be no inquest.  
  • If the post-mortem examination reveals that  the deceased died of natural causes but the coroner considers that it is necessary to (investigate or) continue the investigation, then the coroner will hold an inquest.  
  • If, after the post-mortem examination,  the coroner (still) has reason to suspect that the deceased died a violent or unnatural death, or the cause of death is unknown, or the deceased died while in custody/state detention, then the coroner must hold an inquest. 

Why does the Coroner sometimes arrange a second post mortem?
If no-one has been charged in connection with a homicide offence and the police do not expect to make an arrest within 28 days, the coroner will arrange for a second post mortem examination by a pathologist independent of the first, (Home Office Circular No 30 / 1999 and paragraph 10 of accompanying Memorandum of Good Practice re early release of bodies in cases of suspicious deaths).    

The second post mortem examination will allow the coroner to release the body, but retain the report for use by the defence if, in due course, an arrest is made and charges brought. The purpose of the second post mortem is to enable the defence to have access to a properly informed independent expert witness. It is not a second post mortem for the police, although in some cases the first pathologist and Senior Investigating Officer may be present at the second post mortem and therefore broadly aware of the likely conclusions. 

What is a pre-inquest review meeting?
If the case is complex, before holding a full inquest,  the Coroner will normally hold a pre-inquest review meeting, to which immediate family and “Properly interested parties” will be invited. The pre-inquest review hearing is your opportunity to comment, and perhaps alter, the Coroner’s view of how, and even when, the inquest should be conducted, for example, by you suggesting the witnesses who should be called in person. 

If the case is complicated, for example, when there are lots of witnesses and other interested persons, there may be one or more pre-inquest hearings or reviews. These are hearings with the coroner and all the interested persons, where plans are made for the practical arrangements, such as agreeing an inquest date, deciding on which witnesses will be needed and how long the inquest is going to take.  

You can go along to these hearings, or you may want your solicitor to deal with them for you. 

Communicating with the Coroner
Generally you will be dealing with the coroner’s officer, although some coroners will speak directly to bereaved people or their solicitors. 

Being represented by a solicitor
If you have a solicitor, it is important he or she lets the coroner know as soon as possible that they are instructed by you to prepare for the inquest, and that they keep in regular contact with the coroner. 

Note that it is extremely unusual for Legal Aid to be available for families in connection with Inquests. 

It is up to the coroner to decide who will give evidence. You can suggest witnesses who may be helpful and important to the coroner yourself, or through your solicitor. 

Coroners may release a witness list of who they propose to call to give evidence in advance of the inquest. A coroner will either call a witness to give evidence in person at the hearing, or will arrange for their statement to be read at the inquest, without the need for them to attend (rule 37 of the Coroners Rules 1984). If you object to a statement simply being read out, then it should not be, and the witness should be called to appear at the inquest in person. 

Date of the Inquest
You should be informed of the date of the inquest as soon as it is set. If there is a pre-inquest review meeting, the inquest date will be agreed at that time. You will be able to tell your solicitor if there are any dates that would be difficult for you to attend and they can ask the coroner to take this into account when setting the full inquest date. 

If the death raises complicated issues and involves investigations by other organisations (for example, insurance companies), you may need to be prepared to wait many months, or in some circumstances years, before the inquest takes place. In some complex cases this can be as long as four or five years after the death. 

Media interest
You do need to be very careful and seek advice from your solicitor about what (if anything) it is sensible to say in public before the inquest, as it could have a negative impact. For example, if there is the possibility of someone being charged with a criminal offence, it is not usually a good idea to speak publicly about the facts or events involved in the death.  If there are civil proceedings taking place, you also need to have good advice about what you can say and when you can say it. 

Where will the inquest be held?
Inquests are normally held in the Coroner’s Court, although in cases with significant public interest, a larger venue may be selected. Anyone can attend, and families can chose to be represented if required, by a solicitor or barrister, or may chose to speak for themselves. 

What will happen at the inquest?
At the inquest the Coroner will conduct the proceedings, by having witness statements read out, or by interrogating the witnesses that have been summoned. A witness, if summoned, must appear. The Coroner will lead the questioning of witnesses, but will also allow relevant questions from any of the following categories of people either directly, or through their legal representative. These categories of "Properly Interested Persons" are:

a)    Parent, child, spouse or representative of the deceased
b)    Any beneficiary under insurance
c)    The insurer who issued such a policy
d)    Any person whose act, or omission may have caused or contributed to the death
e)    Any person appointed by a trade union to which the deceased belonged, if that employment may have caused or contributed to the death
f)    An inspector appointed by an enforcing authority or government department.
g)    The Chief Officer of Police
h)    Any other person who, in the opinion of the Coroner is a “properly interested person”.

Inquest  conclusions
At the end of an inquest,  the coroner (or jury if applicable) completes a  form entitled ‘Record of an inquest’. This form documents the ‘conclusion’ of the coroner or jury.  A conclusion consists of the legal ‘determination’,  which states who died, and where, when and how they died;  and ‘findings’ which allow the cause of death to be registered. The coroner or jury may commonly use one of the following short form conclusions, but this is not an exhaustive list:

  • accident or misadventure
  • alcohol/drug-related  
  • industrial disease  
  • lawful killing  
  • unlawful killing  
  • natural causes  
  • open verdict
  • road traffic collision  
  • stillbirth  
  • suicide, or

alternatively a “Narrative Verdict” can be used, i.e. a longer explanation if the cause(s) of the death are sufficiently complex, or do not fit a short form conclusion. 

Additionally, a Coroner may make recommendations as to how similar deaths might be avoided in the future. 

The importance of an Unlawful Killing conclusion
In almost all of our member’s cases, what the family is hoping to achieve from the Coroner’s inquest is a verdict of “Unlawful Killing”. Why is this so important? Whilst a Coroner’s verdict cannot be in conflict with a prior Criminal court verdict, an “Unlawful Killing” verdict can sometimes be the trigger for further action by the Police, the Crown Prosecution service, and can sometimes affect Civil proceedings. Additionally, a Coroner’s inquest may bring to light “new evidence”. 

223,841 deaths were reported to coroners in 2014,  a decrease of 4,143 (2%) from 2013.  Just under half (45%) of all registered deaths were reported to coroners in 2014, the same level as seen in 2013. Over the last ten years this proportion has been relatively consistent, within the range of 45% to 47%. Post-mortem examinations were ordered by coroners in 40% of all cases reported to them in 2014. Following the implementation of the Coroners Act 2009 in July 2013, coroners are allowed to hold post-mortems as part of a brief investigation before deciding if an inquest needs to be opened.  Just three of the ten possible inquest conclusion “short  forms” account for almost 62% of all conclusions recorded  (accident and misadventure: 27%, unclassified: 18% and natural causes: 17%). Between 2010 and 2013, ‘natural causes’ was the most commonly used inquest conclusion - however compared with 2013, the number of  “natural causes” fell by 45% in 2014. This may partly be due to the decrease in the number of cases reported to coroners, but in addition, may also be due to the Coroners Act 2009 coming into effect in July 2013. This means that coroners can now issue a death certificate without holding an inquest when it is known that a death has occurred naturally. The estimated average time taken to process an inquest in 2014 (from the date the death was reported until the conclusion of the inquest, where the death occurred in England and Wales) was 28 weeks, with a minimum of 3 weeks and maximum 53 weeks across all coroner areas. Coroners are under pressure to conclude within 12 months, because at that point the Chief Coroner can take over the case, and in any event, has to include it in the statistics that he reports to parliament each year. 

More information:
Guide to Coroner Services