Coroners and Inquests Booklet

8/14/2019 Coroners and Inquests Booklet

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A guide to

Coronersand Inquests


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A guide to

Coronersand Inquests


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1. What is a coroner? 32. What do coroners do? 43. What is the role o a coroners o cer? 44. Are all deaths reported to a coroner? 5

5. When is a death reported to a coroner? 56. What will a coroner do when a death is reported? 67. What is a post-mortem examination? 68. Post-mortem examination report 79. Medical records 710. Will organs be retained a ter a coroners 8

post-mortem examination?

11. Donation o tissue and organs or transplantation 912. What happens a ter the post-mortem examination 9i the coroner decides to hold an inquest?

13. Taking the body abroad or bringing it back to this country 1014. What is an inquest? 1115. What happens i somebody has been charged with 11

causing the death?

16. Attendance at an inquest 1217. Is there always a jury at an inquest? 1218. Who decides which witnesses to call? 1219. Must a witness attend court? 1320. Who can ask witnesses questions? 1321. Who is a properly interested person? 1322. Is Legal Aid available? 14

23. Inquest verdicts 15

Contents


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24. What i uture deaths may be prevented? 15

25. What can you do i you are dissatis ed with the 16outcome o an inquest?

26. Is it possible to obtain a record o the inquest? 1627. Will the inquest be reported by the media? 1728. What about other proceedings? 1829. Rights o properly interested persons, including 18

bereaved people,throughout the process

30. How can you nd out urther in ormation? 19


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Coroners and inquests a guide

Some questions answered and issues explained

This guide is or in ormation purposes only and is not intendedto be an exhaustive explanation o current coroner law in Englandand Wales. I you are a properly interested person in a speci cinquest (see section 21) and have questions about it, you shouldraise these with the coroners o ce.

The Coroners and Justice Act, which received Royal Assent on 12November 2009, introduces a number o signi cant re orms to thecoroner system and they will be introduced as soon as possible.Further in ormation about the re orm programme can be seen athttp://www.justice.gov.uk/publications/coroners-justice-bill.htm.A revised version o this guidance will be published when the Acthas been implemented.

1. What is a coroner?

1.1 Acoroner is an independent judicial o ce holder, appointedand paid by the relevant local authority. A coroner must be alawyer or a doctor, and in some cases is both. Each coroner hasa deputy and usually one or more assistant deputies, and eitherpersonally or through a deputy he or she must be available at alltimes. The costs o the coroners service are generally met by localauthorities, not by central Government. In some districts the localpolice orce may also contribute towards a coroners resources,usually by providing and paying the costs o coroners o cers.


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2. What do coroners do?

2.1Coroners inquire into violent or unnatural deaths, suddendeaths o unknown cause, and deaths which have occurred inprison. A coroners authority to inquire fows rom the report o abody being within the coroners district and not rom where thedeath occurred. The coroners inquiries may take one o several

orms and may result in the holding o an inquest.

2.2 It is a coroners duty at an inquest to establish who thedeceased was and how, when and where the deceased came by hisor her death. A ter an inquest the coroner will send the necessarydetails to the registrar o births and deaths or the death to beregistered when it occurred in England and Wales. An inquestis not permitted to determine or appear to determine criminalliability by a named person or civil liability. It is about whathappened, not who was responsible or what happened, or whichthe civil and criminal courts have jurisdiction.

2.3 In some cases a death may be re erred to the police orinvestigation on behal o a coroner. In other cases a separateinvestigation into a death may be undertaken by an independentbody such as the Health and Sa ety Executive, the Prisons andProbation Ombudsman, the Care Quality Commission or theIndependent Police Complaints Commission, and the coroner willbe given the results o the investigation.

3. What is the role o a coroners o fcer?

3.1Coroners o cers work under the direction o coroners andliaise with bereaved amilies, the police, doctors, witnesses and

uneral directors. They receive reports o deaths and make inquiries

at the direction, and on behal , o a coroner.


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4. Are all deaths reported to a coroner?

4.1 No, not all deaths need to be reported. In many cases thedeceaseds own doctor, or a hospital doctor who has been treatinghim or her during the nal illness, is able to issue a MedicalCerti cate o the Cause o Death (MCCD) without re erence toa coroner. The death can then be registered by the registrar obirths and deaths, who will issue the death certi cate. Sometimesdoctors may discuss the case with the coroner and this may resultin the coroner deciding that he or she does not need to make

urther inquiries, because the death is rom natural causes. In thelight o that discussion the doctor concerned may be able to issuethe MCCD and the coroner will issue a certi cate to the registrarstating that it is not necessary to hold an inquest.

4.2 However, i the coroner has decided to investigate a death theregistrar o births and deaths must wait or the coroner to nish hisor her inquiries be ore the death can be registered. These inquiriesmay take time, so it is always best to contact the coroners o cebe ore any uneral arrangements are made. In many cases thedecision to investigate will not hold up uneral arrangements

5. When is a death reported to a coroner?

5.1Registrars o births and deaths, doctors or the police reportdeaths to a coroner in certain circumstances. These include whereit appears that:

no doctor attended the deceased during his or her lastillness;although a doctor attended during the last illness thedeceased was not seen either within 14 days be ore deathnor a ter death;

the cause o death appears to be unknown;

the death occurred during an operation or be ore recovery


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rom the e ects o an anaesthetic;

the death was due to an industrial accident, diseaseor poisoning;the death was sudden or unexpected;the death was unnatural;the death was due to violence or neglect;the death was in other suspicious circumstances; orthe death occurred in prison or police custody.

6. What will a coroner do when a death is reported?

6.1The coroner may decide that a post-mortem examination andinquest are unnecessary because the cause o death is evident,and there is a doctor who can sign an MCCD to that e ect. In suchcases the coroner will advise the registrar o births and deaths thatno urther investigation is needed.

6.2 The coroner may ask a pathologist to examine the body andcarry out a post-mortem examination (also known as an autopsy).I so, the examination must be made as soon as possible.

7. What is a post-mortem examination?

7.1A post-mortem examination is a medical examination o a body,

carried out or a coroner by a pathologist o the coroners choice,in order to establish the cause o death.

7.2The coroner is not required to obtain the consent o therelatives or a post-mortem examination to be made, but isrequired to in orm certain persons o when and where theexamination will take place. These include the deceasedsrelatives and others with an interest in the death, or example,

the deceaseds regular medical practitioner and the Chie o Police.Such persons are entitled to be represented at the examination by


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a doctor o their choice, but they have to pay any ee the doctor

may charge. Coroners will where possible take account o religiousand cultural needs.

7.3 I concerns remain about the cause o death, the relativescan ask the coroner or a separate, additional post-mortemexamination, which would be at their own expense.

8. Post-mortem examination report

8.1This report gives details o the examination made o thebody, and is sent to the coroner by the person who carried outthe post-mortem examination. It may also give details o anytests which have been carried out to help determine the causeo death. Copies o the report are normally available only toproperly interested persons. A ee or the copies may be payable.

8.2 A coroner may dispense with an inquest a ter a post-mortemexamination i he or she thinks an inquest is unnecessary and thereis no reason to suspect that the person died a violent or unnaturaldeath, and they did not die in prison. The coroner will release thebody or the uneral and send a orm to the registrar o births anddeaths stating the cause o death as disclosed by the post-mortemexamination report, so that the death can then be registered.Generally this will happen when the post-mortem examinationestablishes that the person died o natural causes and the coronerdecides no urther investigation into the death is necessary.

9. Medical records

9.1Medical records remain con dential a ter death but may bemade available to the deceaseds personal representative or anyperson who may have a claim arising out o the deceaseds death,


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subject to some restrictions, under the terms o the Access to

Health Records Act 1990. These can be viewed online at:http://www.opsi.gov.uk/acts/acts1990/Ukpga_19900023_en_1.

9.2 Coroners are entitled to obtain copies o medical in ormationthat is relevant and necessary to their inquiries. Medicalin ormation about the deceased may be disclosed at the inquesthearing i it is relevant to the cause o death.

10. Will organs be retained a ter a coroners post-mortemexamination?

10.1Distressing though it can be or the deceaseds amily, organsand tissue may sometimes be removed rom a body and preservedby a pathologist i they have any bearing on the cause o death orthe identity o the deceased. When the material no longer needs to

be preserved it will either be returned to the deceaseds amily orrepresentative, i requested, or disposed o by burial or cremation.I a pathologist believes it would be appropriate to retain organsand tissue, or example or use in research or or training purposes,the consent o the relatives must be obtained. In some exceptionalcases, e.g. involving murder, the organs may have to be retained

or a longer period.

10.2 Further general in ormation on tissue retention and the legalrequirements relating to consent can be obtained rom the HumanTissue Authority on 020 7211 3400 or online atwww.hta.gov.uk.


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11. Donation o tissue and organs or transplantation

11.1I the next-o -kin wishes to consider donation, immediateadvice is essential. This can be sought rom a hospital or romthe local Transplant Co-ordinator, who will be able to discuss theoptions or donation in more detail. The Transplant Co-ordinatormust consult the coroner in any case which has been or is likelyto be re erred to him or her, and the coroner must agree be ore adonation can take place, since the removal could a ect importantevidence. These decisions are usually made very quickly. In asmall number o cases, or example where there is a criminalinvestigation, organ donation may not be possible.

12. What happens a ter the post-mortem examination ithe coroner decides to hold an inquest?

12.1A coroner must hold an inquest i the cause o death remainsunknown, or i there is cause or the coroner to suspect that thedeceased died a violent or unnatural death, or died in prison.However, a ter the post-mortem examination is completed thecoroner will normally issue the necessary authority permitting aburial or cremation, so that a uneral can be held, even though theinquest has not been concluded.

12.2In such circumstances the death cannot be registered.In order to assist the administration o the estate, an interimcerti cate o act o death can be issued by the coroner. Thiscerti cate should be acceptable to banks and nancial institutions,unless it is important or them to know the outcome o the inquest( or example, or an insurance settlement). You can also use thisinterim certi cate or bene t claims and National Insurancepurposes. When the inquest has been completed the coroner

will noti y the registrar o births and deaths so that the death canbe registered by the registrar and a death certi cate can then beobtained rom the registrar.


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12.3I criminal charges have been brought against somebody or

causing the death, it may be necessary or a second post-mortemexamination to take place or or urther investigation, and therelease o the body and the uneral arrangements may then haveto be delayed.

13. Taking the body abroad or bringing it back to thiscountry

13.1In every case where someone wishes to take a body out oEngland or Wales, written notice must be given to the coroner inwhose area the body is located. The coroner will then considerwhether an inquest or post-mortem examination is needed andwill noti y his or her decision within our days.

13.2 I a body is being brought into England or Wales, the coronerin the area to where the body is brought may need to be involved.The coroner may need to determine the cause o death and willbe required to hold an inquest i the death was unnatural, orviolent, or sudden and o unknown cause. The coroner will issue acerti cate or cremation in all cases coming rom abroad where thebody is to be cremated.

13.3When death has occurred outside England and Wales and thebody is returned to England or Wales, the death is not registeredby the registrar o births and deaths when the coroner has nishedinvestigating or has concluded the inquest. Further in ormationabout what to do when a death occurs abroad can be ound on theForeign and Commonwealth O ces website, at:http://www. co.gov.uk/en/travel-and-living-abroad/when-things-go-wrong/death-abroad


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14. What is an inquest?

14.1An inquest is a act- nding inquiry to establish who has died,and how, when and where the death occurred. It does not havestatements and examination o witnesses by prosecution andde ence teams, like a criminal trial; the coroner and all those withproper interests simply seek the answers to the above questions.

14.2An inquest is usually opened soon a ter a death to record thata death has occurred, to identi y the deceased, and to enable thecoroner to issue the authority or the burial or cremation to takeplace without any unnecessary delay. It will then be adjourneduntil any other investigations (see paragraph 2.3) and any inquiriesinstigated by the coroner have been completed. It will usually takebetween 3 and 9 months to conclude this work, but some casescan take longer than this i the inquiries prove to be complicated.The inquest will then be resumed and concluded.

15. What happens i somebody has been charged withcausing the death?

15.1Where a person has been sent or trial or causing a death, orexample by murder or manslaughter, any inquest is adjourned untilthe criminal trial is over. On adjourning an inquest, the coroner

must send the registrar a certi cate stating the particulars that areneeded to register the death and or a death certi cate to be issued.When the trial is over, the coroner will decide whether to resumethe inquest. There may be no need, i all the acts surrounding thedeath have emerged at the trial. I the inquest is resumed, however,the nding o the inquest as to the cause o death cannot beinconsistent with the outcome o the criminal trial.

15.2Section 28 below sets out the position where civil proceedingshave been brought in connection with a death.


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16. Attendance at an inquest

16.1When a coroners investigations into a death are complete, adate or a ull inquest will be set. The properly interested persons(see paragraph 21 below) will be in ormed o the date by thecoroners o cer and any witnesses will be asked to attend toprovide evidence. The process is held in the public interest andnot on behal o any individual. It is not always necessary or thebereaved relatives to attend the inquest, and some pre er not toas the details o the death may need to be dealt with in graphicterms. I you do attend the inquest you can be accompanied by asupporter, or example a riend.

17. Is there always a jury at an inquest?

17.1No, most inquests are held without a jury but there areparticular circumstances when a jury is called, including:

i the death occurred in prison or in police custody; ori the death resulted rom an accident at work.

17.2In every jury inquest, the coroner decides matters o law andprocedure, and the jury decides the acts o the case and reachesa verdict. The jury cannot blame someone or the death. I there isany blame, this can only be established by other legal proceedingsin the civil or criminal courts, although the jury can state actswhich make it clear that the death was caused by a speci c ailureo some sort or by neglect.

18. Who decides which witnesses to call?

18.1The coroner will decide who should be called to give evidenceas a witness, and the order in which they give evidence. However,

anyone who believes they may be o help or believes a particular


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anyone whose action or ailure to act may, in the coroners

view, have contributed to the death;the Chie O cer o Police (who may only ask witnessesquestions through a lawyer);any person appointed as an inspector or a representativeo an en orcing authority or a person appointed by aGovernment Department to attend the inquest; oranyone else who the coroner may decide also has a properinterest.

21.2It is the coroner who decides who will be given properlyinterested person status.

22. Is Legal Aid available?

22.1Legal Aid is not generally available or representation atinquests because an inquest is a act- nding process. Unlikeother proceedings or which Legal Aid might be available, thereare no parties in inquests, only the properly interested persons,and witnesses are not expected to present legal arguments.The coroner ensures that the process is impartial and thorough,and he or she should assist amilies to ensure that their relevantquestions are answered.

22.2 Legal Aid may, however, be available to cover representationat the inquest in very exceptional cases. Applicants must quali y

nancially and meet strict criteria or representation to be unded.These criteria are that:

there is a signi cant wider public interest in the applicantbeing represented at the inquest; orthe circumstances o the death appear to be such that

unded representation is likely to be necessary to enablethe coroner to investigate the case e ectively andestablish the acts, providing that the applicant was a


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member o the deceaseds immediate amily (as required

by Article 2 o the European Convention on HumanRights).

22.3 However, legal advice - via the Legal Help scheme - may beavailable to those who quali y nancially. Further in ormation isavailable rom the Legal Service Commission on

0845 345 4345 or online at www.legalservices.gov.uk.

23. Inquest verdicts

23.1Possible verdicts include:natural causes;accident or misadventure;he or she killed him/hersel (i.e. suicide);unlaw ul killing;law ul killing;industrial disease; oropen verdict (where there is insu cient evidence or anyother verdict).

23.2 Alternatively, the coroner can give a narrative verdict whichsets out the acts surrounding the death in more detail andexplains the reasons or the decision.

24. What i uture deaths may be prevented?

24.1Sometimes an inquest will show that something could bedone to prevent other deaths. I so, at the end o the inquestthe coroner may announce that he or she will draw this to theattention o any person or organisation that may have the powerto take action. This is something re erred to as a Rule 43 Report

as the power to make such a report is ound in Rule 43 o theCoroners Rules 1984. This Rule was signi cantly changed in 2008.


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Now anyone who receives such a report must send the coroner a

written response. These reports, and the responses to them, arecopied to all interested persons and to the Lord Chancellor.A summary o the reports is published twice a year, by theMinistry o Justice.

25. What can you do i you are dissatisfed with theoutcome o an inquest?

25.1It is possible to challenge coroners decisions and inquestverdicts, but the grounds or doing so are complex and adviceshould be sought rom a lawyer with expertise in this area o thelaw. An application may be made to the High Court or judicialreview o a decision, but this must normally be done within threemonths o completion o the inquest. There is a separate powerunder which the Attorney-General may initiate an application to

the High Court or an inquest to be held i a coroner has neglectedor re used to hold one, or or another inquest to be held on thegrounds that it is necessary or desirable (e.g. because new evidencehas come to light).

26. Is it possible to obtain a record o the inquest?

26.1Once an inquest has been completed, a properly interested

person may apply to see the notes o evidence, any documentput in evidence at the inquest, or a copy o any post-mortemexamination report. Copies may be obtained ollowing payment oa ee to the coroner. The notes may be in the orm o a transcript

rom a tape-recording or the coroners own notes. The coronersnotes may not be a ull, verbatim record.


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27. Will the inquest be reported by the media?

27.1All inquests must be held in public in accordance with theprinciple o open justice, and so members o the public and journalists have the right to, and indeed may, attend (althoughparts o a very small number o inquests may be held in private ornational security reasons). Whether journalists attend a particularinquest and whether they report on it - is a matter or them. Iany such report is air and accurate it cannot be used to sue orde amation.

27.2Those working on newspapers or magazines abide bythe Editors Code o Practice, upheld by the Press ComplaintsCommission, which sets out the guidance or print journalistsin the UK. The Code, which can be seen at www.pcc.org.uk, hasrequirements on accuracy, privacy and discrimination. It alsohas speci c rules in cases involving grie and shock. For instance,publication in such circumstances must be handled sensitivelyand, when reporting suicide, care should be taken to avoidexcessive detail about the method used.

27.3The Press Complaints Commission (PCC) mostly deals withcomplaints about published material. However, it can also helpto prevent physical harassment by journalists and will sometimesbe able to assist with problems related to material that has not yet appeared in print. Its sta are always happy to discuss mattersin ormally; the PCC can be contacted on 020 7831 0022 or0845 600 2757. It also operates an out-o -hours numberforemergencies only (07659 152656). 27.4 Suicide notes and personal letters will not usually be readout at the inquest, unless the coroner decides it is importantto do so. I they are read out, their contents may be reported.Although every attempt is made to avoid any upset to peoples


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private lives, sometimes, in the interest o justice, it is unavoidable.

Photographs taken o the deceased and o the scene o death mayalso orm part o the evidence presented in court.

28. What about other proceedings?

28.1Any civil proceedings will normally ollow the inquest. Whenall the acts about the cause o death are known it is possible thatcivil proceedings may be brought and a claim or damages made.A lawyers advice should be sought about the time limits andprocedures that apply. Inquest evidence cannot be used directlyin other proceedings.

29. Rights of properly interested persons, includingbereaved people, throughout the process

29.1Essentially, properly interested persons at an inquest havethe right:

to be told the date, time and place o the inquest i oneis needed; andto question witnesses at the inquest, or have a legallyquali ed representative do so.

29.2 Bereaved people may also:

ask the coroner, via the uneral director, or reasonableaccess to see the body be ore it is released or the uneral;ask the coroner or a copy o the post-mortemexamination report ( or which a ee may be payable), orto arrange or it to be seen ree o charge; andask the coroner about a separate post-mortemexamination. The costs o this examination, including any

ee o the registered medical practitioner and mortuarycharges, would have to be sel - unded.


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30. How can you fnd out urther in ormation?

30.1You can obtain more in ormation, including details o anylocally-operated Coroners Charter, rom your local coronerso ce. This is usually listed in the telephone directory or on thewebsite o the local authority or the area. Alternatively, yourlocal police, hospital or Citizens Advice Bureau will be able to tell you where the o ce is situated.

30.2 A urther source o general in ormation is the pre-recordedMetropolitan Police Bereavement In ormation Line on

0800 032 9996. This is available to listen to 24 hours a day.

30.3 Jobcentre Plus publish a bookletWhat to do after a death inEngland and Wales , (DWP 1027) which covers legal and bene tsprocedures. Registrars o births and deaths will give a copy topeople who register a death, and coroners may make copiesavailable to bereaved amilies. The booklet can be viewed onlineat: http://www.dwp.gov.uk/publications/catalogue-o -in ormation/all-products/

30.4 Further in ormation about coroners, death registration andrelated matters are available online at www.direct.gov.uk.

30.5 I you have any general queries about the contents othis leafet please email [email protected] or phone

020 3334 3555.


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Jan 2010Coroners and Burials DivisionMinistry o Justice

Documents

Coroners and Inquests Booklet