How to: The role and duties of the coroner

Introduction

Before a body is buried or cremated the law requires that either a doctor must provide a certificate or a coroner must make an order as to the cause of death. This protects the public interest by ensuring that every person who dies is identified and that the cause of death is established. This helps ensure that crimes do not go undetected.

Doctor's certificates as to cause of death

If a doctor who is called at the time of death is satisfied that it was from natural causes, then the doctor will sign a medical certificate as to the cause and a funeral director may proceed with funeral arrangements immediately.

Doctors must report deaths to Police in certain cases

However, if the death has occurred in violent, unnatural or suspicious circumstances then the doctor is required to report the death to the Police, who in turn report it to the coroner. This will apply if, for example:

  • a person seems to have died in a violent or unnatural way, such as by drowning, in a car accident or by poisoning
  • the cause of death is unknown
  • a person dies while under anaesthetic or during a medical operation or procedure, or the death appears to have been a result of the anaesthetic or operation or procedure
  • a person dies in prison or Police custody
  • a person dies in a place such as a psychiatric institution or children's home
  • a person appears to have taken his or her own life

The coroner then decides whether or not an inquest is necessary (see below). If it is not necessary, the doctor may issue a medical certificate as to the cause of death.

Deaths in hospital

Not all deaths that occur in hospital must be reported to the coroner; rather, it will depend on the circumstances. If the patient died while under anaesthetic or during a medical operation or procedure, or if it seems that the death resulted from the anaesthetic or the operation or procedure, the coroner must be notified.

The coroner's powers and functions

The coroner is given wide discretion under the law to make inquiries and publicly investigate deaths, including the power to summon witnesses to an inquest. When a death is reported to the coroner, the coroner must establish a cause of death. The coroner may require a pathologist (a medical specialist in diseases) to establish the cause. Other specialists may be called in if a particular cause of death is suspected – for example, poisoning.

Frequently the Police carry out investigations on the coroner's behalf.

Inquests in the Coroner's Court

The coroner may hold a public inquiry, referred to as an "inquest", to establish the facts of a death. Inquests are held in the Coroner's Court for the purpose of establishing, as far as is possible,

  • that a person has died
  • the person's identity
  • when and where the person died
  • the cause of the death, and
  • the circumstances of the death

Evidence surrounding the death is presented in open court. An inquest is a fact-finding exercise, rather than a method of assigning guilt.

In general, a coroner is required to hold an inquest into a reported death if it appears to have been suicide or appears to have occurred while the person was either detained in an institution or in Police custody or in prison.

The coroner has the power to summon witnesses to an inquest.

Post-mortems (autopsies)

A post-mortem examination (or autopsy) refers to an examination of a body to establish the cause of death. If a coroner orders a post-mortem examination then funeral arrangements can proceed only after the coroner has signed the burial order. Before doing this the coroner must make sure that the body has been identified by the next of kin or that there is sufficient evidence to be given at an inquest.

In deciding whether or not to order a post-mortem, the coroner will consider the following matters:

  • the likelihood of revealing information as to when, how and where the deceased died, or information about the deceased's identity
  • any distress or offence that may be caused to the deceased's family due to their particular ethnic or spiritual beliefs
  • the likelihood that the death was caused by another person
  • the existence of any allegations or suspicions about the cause of death
  • the wishes of the deceased's immediate family
  • whether the cause of death can be determined without a post-mortem

A post-mortem usually involves an inspection of internal organs by a pathologist as well as of any external injuries. The pathologist will repair any incisions made during a post-mortem and ensure that the body is left as presentable as possible. If it is necessary for the pathologist to retain an organ for further examination, he or she must seek to return the organ for burial or cremation. If this is not possible, the coroner must notify the deceased's family immediately.

Release of bodies for burial or cremation

When a medical certificate is issued as to the cause of death, the deceased's body will be released for burial or cremation. If the death is reported to a coroner, the body will be released after the coroner has signed a burial order. There may be some delay if a post-mortem is required, but it is usual for a body to be released within 24 hours.

It is, however, possible that it may take longer – for example, if the nearest pathologist is some distance away or if specialists need to be called in to give an assessment. If a specific cultural or spiritual belief is at issue, then this may also cause some delay.

Cautionary notes
  • If a body is to be cremated, a certificate from a medical referee is required under the CREMATION REGULATIONS 1973.
  • Any person who finds a dead body or who knows that violent or unnatural causes may have been involved in a death must report this to the Police, who will in turn inform the coroner.


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