A coroner investigates deaths that appear violent or unnatural, where the cause is unknown, or where the person died in prison, police custody or other state detention. GOV.UK says its rules apply if you live in England and Wales; Scotland and Northern Ireland use different processes. The Ministry of Justice guide for bereaved people (January 2020) explains what follows a report to the coroner.
What a coroner does
The guide describes a coroner as a special type of judge, appointed by a local authority but independent, who works within a legal framework mainly set by the Coroners and Justice Act 2009. The coroner’s task is to find out who died and how, when and where. A coroner’s investigation is not a criminal investigation, and the coroner cannot find anyone guilty or civilly liable; those questions belong to other courts. Where evidence suggests someone may be criminally responsible, the coroner can pass it to the police or Crown Prosecution Service.
GOV.UK says a coroner might decide no investigation is needed, might find the cause clear and issue a certificate that an inquest is not needed, or must hold an inquest if the cause is still unknown, the death may have been violent or unnatural, or it may have occurred in prison or police custody. A post-mortem may be ordered, and GOV.UK says it cannot be objected to.
Interested persons and disclosure
Close relatives and personal representatives count as “interested persons” under section 47(2) of the 2009 Act. The guide says they have the right to be told the dates of hearings, to receive evidence such as witness statements and expert reports (disclosure), to attend, to ask relevant questions of witnesses and to bring a person for support. The coroner’s office cannot give legal advice, and in a long investigation it should update relatives at least every three months. The guide says the coroner’s office must tell relatives the date, time and place of an inquest within a week of fixing it, and that all inquest hearings are recorded, with a right to ask for a recording. Copies of documents are free before and during the inquest, though a charge may apply afterwards, and the coroner should explain if any document or part of one cannot be provided.
How the inquest runs
An inquest is a public court hearing to decide who died and how, when and where. It should take place within six months, or as soon as reasonably possible, and the guide says a coroner who has not finished within 12 months must report to the Chief Coroner giving reasons. The inquest is usually opened briefly and then adjourned; in complex cases there may be pre-inquest review hearings to decide scope, documents and witnesses.
Only the coroner decides which evidence to hear. There is no prosecution or defence. A jury is needed for deaths in prison, police custody or other state detention (except natural causes), for deaths from an accident at work, and where the senior coroner thinks there is sufficient reason. Attendance is optional unless the person is asked to give evidence, in which case a written statement may replace attendance if the coroner agrees.
Conclusions and prevention of future deaths
At the end, the coroner or jury gives a conclusion, such as accidental death or misadventure, natural causes, suicide, lawful or unlawful killing, road traffic collision, or an “open” conclusion where evidence is insufficient. A short narrative conclusion may be used in more complicated cases. The guide adds that where a death could be prevented in future, the coroner must write a report to the relevant organisation, which must send a written response within 56 days.
Challenging a decision and complaints
A decision or conclusion can only be challenged in limited circumstances. The guide says the route is an application to the High Court for permission to seek judicial review, which must be made as soon as possible and no later than three months from the decision or end of the inquest, or an application involving the Attorney General for a fresh investigation. It recommends specialist legal advice. Complaints about a coroner’s personal conduct can go to the Judicial Conduct Investigations Office, and complaints about service to the coroner and the funding local authority.
FAQs
Do I have to go to the inquest?
Not unless asked to give evidence, according to the guide. Relatives are free to attend, and a supporter can come along.
Can the coroner say who was to blame?
No. The guide says a coroner or jury cannot find anyone criminally responsible or liable under civil law; those decisions belong to other courts.
Where can I get free support?
GOV.UK names the Coroners’ Courts Support Service, whose helpline for England and Wales is 0300 111 2141.
Bottom line
An inquest is a fact-finding hearing, not a trial. Relatives who are interested persons have the right to disclosure, to attend and to question witnesses, and a challenge must be brought promptly and usually through the High Court. This guide is general information based on official guidance and does not replace legal advice for a specific case.