About the coroner



The Coroner is a judge with the power to conduct investigation into an unexplained death. As a judge, the Coroner is independent of the council and its authority.

The Coroner takes referrals from the police, hospitals, GPs, registrars, and other professionals to decide whether the death should be investigated. If it does need investigation, then the coroner can choose to perform an inquest. An inquest sets out to answer the following four questions:

  1. Who was the person who has died?
  2. When did they die?
  3. Where did they die?
  4. How did their death come about?

On occasion, the Coroner will also look at the circumstances surrounding the death. The Coroner may also need to use any information discovered during the investigation to help prevent future deaths arising from similar circumstances.

Why a death is referred to the Coroner

When a person dies and the cause of death isn't clear it may be referred to the Coroner for investigation. This can include circumstances where:

  • The death was violent or unnatural
  • The cause of death was unknown
  • The death occurred whilst in custody or otherwise in state detention
  • The death occurred as a result of an incident at work

There are lots of other reasons why a death might be referred to the Coroner, but these are the most common. Referral of a death to the Coroner does not necessarily mean that the death is suspicious. It does mean that the professional involved at the point of death felt that it should be checked by an independent body to establish exactly what happened.

What happens next?

Coroner's investigations may involve four main steps – these are explained below.

1. Referral

The police, hospitals, GPs and other professionals may refer a death where they think it should be investigated by the Coroner. The Coroner will review the evidence to decide whether it is appropriate to investigate. If it is then they may move on to the following stages.

2. Post-mortem

If a Coroner decides that a post-mortem is required, they will instruct a pathologist to carry it out. A post-mortem is conducted by a pathologist to determine how a person died. When this is completed the pathologist will send their report to the Coroner. It will explain their findings which, hopefully, will include the likely cause of death.

3. Investigation

If further enquiries are needed a Coroner will commence an investigation to decide whether an inquest is required. If so, then they will proceed to step four.

4. Inquest

A Coroner will hold a court hearing to determine the answers to the questions mentioned above. At the end of the hearing, the Coroner will set out the circumstances and causes of death as well as any other conclusions they have drawn from their investigation. Find out more about the inquest process.


The time needed to complete the investigation, possibly including an inquest, depends on many factors. Sometimes this process may take only a few weeks, sometimes a few months, and sometimes much longer to be completed. We will provide you with a named Coroner's officer who will keep you updated on the investigation's progress.

The post-mortem

The Coroner may decide to carry out a post-mortem to investigate the cause of death. If they do so, a pathologist will be called upon to perform this procedure. As part of a post-mortem, samples of organs, tissue, or blood may need to be taken. If this is necessary, you will be contacted and asked whether you want these samples returned to the body or separately laid to rest. Such procedures will always be undertaken in a respectful manner befitting of the remains.

Attending the post-mortem

Unfortunately, you may not attend a post-mortem personally. However, you may appoint a medical practitioner to attend on your behalf. You will be made aware of the date of your post-mortem well in advance so that you will be able to decide if you want such a practitioner to be present.

Objecting to a post-mortem

Your faith may mean that you don't want the Coroner to carry out a surgical procedure to examine the body. If you inform us of such objections, we will make it a priority to try and meet your request where possible. We can sometimes do a non-invasive post-mortem. Unfortunately, non-invasive post-mortems are not always possible because they do not always provide suitable results. It is ultimately the Coroner's decision what type of post-mortem is needed but we will do what we can to accommodate your objections.

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