Guidance

Annex 3: Coroner (England and Wales) roles and responsibilities

Published 31 August 2022

Applies to England and Wales

Background

Coroners are independent judicial office holders (judges). They have statutory responsibility (see section 1, Coroners and Justice Act 2009) to investigate a death reported to them which may be violent, unnatural, of unknown cause or where the cause of death arose in prison or otherwise in state detention as well as in certain other circumstances where the body lies within that coroner’s jurisdiction. These investigations can lead to a type of court hearing, called an inquest.

In cases involving deaths abroad, if there is to be no repatriation of the body, there will be no involvement of, nor investigation conducted by, any coroner in England and Wales. The repatriation of cremated ashes will not incur any coroner involvement.

Not all deaths reported to coroners lead to an inquest. The coroner must first decide whether their duty to investigate the death under section 1 of the Coroners and Justice Act 2009 is triggered.

The Ministry of Justice produces a document called a Guide to Coroner Services which aims to explain the process; please refer to Annex 4 Useful links for the latest version, published in January 2020.

The coroner has lawful control of the body in such circumstances and until such time as a decision is made for the release of the body by the coroner, is the only person who can authorise a post mortem examination.

The Coroners’ service is a local service. England and Wales is divided into a number of Coroner Areas. Areas vary according to the size and nature of its population. Each coronial area has a senior coroner who is primarily responsible for the provision of their local coroner services. The senior coroner is typically supported by other coroners who work within the coroner area, including some who are part time coroners. Judicial work, including inquests, can be carried out by any of the coroners in the area. The coroner service locally is supported by staff (coroner’s officers and other administrative staff) supplied by the local authority and/or local police force. Staffing levels vary from area to area. In some areas the level of support is very limited, as are the resources for administrative and judicial work.

The Chief Coroner, an office created by the Coroners and Justice Act 2009, is the judicial head of the coroner system, providing leadership for coroners in England & Wales.

The coroner’s jurisdiction is territorial, and it is generally the location of a body that determines which coroner may have jurisdiction in any particular case. Subject to the Chief Coroner directing that another coroner deal with a case, or the appointment of a judge to be the coroner (both of which are rare) the coroner for the area where the body is to be buried/cremated will normally take jurisdiction when a body is repatriated.

The inquest

The purpose of the inquest is to provide answers to 4 factual questions: who the deceased person was; and how, when and where they came by their death. In most inquests the ‘how’ component is taken as meaning “by what means” the deceased person came to die, a question directed to the immediate means of death. At the end of an inquest, the coroner or jury make determinations which answers the four statutory questions.

The inquest is not a trial of rights and obligations, but a fact-finding exercise, with no parties or pleadings. The participants are known as ‘interested persons’. The inquest finding cannot determine or appear to determine civil liability. Findings appearing to determine criminal liability are permitted, but not on the part of a named person.

The coroner must ensure that the relevant facts are fully and fairly investigated and are the subject of public scrutiny during the inquest hearing. The coroner alone is responsible for deciding on the scope of the inquest and the evidence to be called. The relevant issues will vary from case to case and may or may not be the subject of disputed evidence. This means that the nature of an inquest (what evidence is heard and what the inquest looks at) can vary from case to case.

There is no provision for the coroner to hold any form of inquiry overseas or to summon witnesses from another country.

The coroner will, as a matter of statutory obligation, inquire into deaths that are violent or unnatural, or where the cause of death is unknown even if the Death Certificate from foreign authorities records that the death was attributed to natural causes. The fact that the medical cause of death is stated to be a natural cause by foreign authorities does not necessarily mean that the death was not unnatural from the point of view of the law in England and Wales. The Coroner may require a post mortem even if one was conducted abroad.

Requests for information when a death has occurred abroad

All requests by coroners for information from foreign authorities are routed through the FCDO Consular Directorate’s Coroners’ Liaison Officer (CLO). The CLO will be asked to forward the request to the relevant consular post overseas who themselves will request the information of the foreign authority. The report, when provided, will then be returned to the Coroner through the same channels. The coroner will ensure that he or she liaises with the CLO (and Family Liaison Officer, where applicable) regularly in advance of the inquest, in order to obtain all relevant information that may be of assistance. Information that may be requested includes:

• death certificate
• post mortem report (including photographs if taken)
• toxicology reports (if samples taken)
• any medical reports
• any photographs, plans or drawings of the scene
• any witness statements
• available Police reports

It is important to note that the above list remains subject to determination by the coroner. The evidence considered by the coroner will vary depending on the facts of each particular case. It is not a legal requirement for coroners to obtain or consider all of the material in this list and the evidence considered by the coroner will vary.

In accordance with the Chief Coroners’ Guidance No. 21 dated 19 October 2015, the translation of documents into English may be required to ensure that bereaved families, as interested persons, are able to participate fully in the inquest process. As this Guidance sets out, which documents should be translated (etc) is ultimately a matter for the coroner to determine. As Guidance 21 says:

Often it will not be necessary to translate in full all (or any) documents which are disclosed. There is no duty on a coroner to disclose in another language. In some instances a coroner may decide that a summary or brief description of one document or a series of documents is sufficient or that key documents or key parts of documents may have to be translated. In each case it is a question of involving the interested person to an appropriate extent…

Disclosure of documents (translated or otherwise) by the coroner should be done so in advance of the inquest to enable proper participation by the bereaved family (and other Interested Persons).

Working with the Police

Coroners routinely rely on other investigative bodies and agencies to provide evidence and information which can form part of the coroner investigation. The police will provide information gathered in the course of their own investigation to the coroner to inform the coronial investigation. The coroner has no power to direct a police investigation. However the coroner may request that the police assist with coronial inquires.