Role of the Coroner

Any death that is sudden of unknown cause occurring in England and Wales (Scotland has a different system) will be referred to the local coroner. A coroner is a judicial officer, appointed to a specific territorial district having responsibility for investigating those deaths that are sudden of unknown cause (as well as those that are violent or unnatural or occur in prison). The investigation that he/she initiates may take a number of different forms but is likely to include discussions with and questions asked of the family, the local GP as well as those who were present when the death occurred and any doctor or nurse who may have tried to revive him/her. The investigation process will probably then include a post-mortem examination that will be made by a pathologist. He/she will seek to find a medical reason or explanation for the sudden death. This examination may entail a detailed examination of tissue taken from the body and specimens of blood and urine. The heart may also be carefully examined by a specialist to see if there is any obvious abnormality which may disrupt its proper function.

This whole investigative process may take some time and the coroner will probably decide that the best way forward is for an Inquest to be conducted. This will give the necessary time and opportunity to those carrying through to complete their investigations. An Inquest need not necessarily delay any funeral arrangements.

When the investigations are complete, the coroner will hold the Inquest (a public hearing) when those who can give information about the death will provide evidence. When all the evidence has been received, the Inquest will be concluded by the coroner reaching a decision as to how the death came about (i.e., the medical cause of death as well as the circumstances directly leading to it). This will all be recorded in a document ending with a conclusion or verdict. The coroner will then complete the death registration with the local registrar of deaths.

The role of the coroner’s officer: The coroner is supported by investigating staff, called coroners’ officers. They are either police employees or civilian staff trained to carry through the directions of the coroner. They will generally be responsible for taking the cases forward and be the person that the family should usually contact to ask questions and discuss the progress of a particular investigation. As necessary, they will keep the coroner informed and take their direction from him/her.

The verdicts and a brief explanation of when/how each might be used in regard to young sudden cardiac death: At the Inquest, the coroner will reach a verdict in accordance with the evidence before him/her. If the evidence shows that the death arose from a naturally occurring disease process (even though it may have been one that was unknown about during life) the conclusion will probably be that the person died from “Natural Causes”. If there was an unnatural element, as may be the case of (for example) a person who had a heart attack while swimming, then the verdict may be one of “Accident”; which might also be given if the person had been using or experimenting with drink or drugs. An “Open” verdict may be given when the evidence does not demonstrate how the death came about and/or the intention of the deceased person is in doubt. A verdict of “Unascertained” may be returned if the medical cause of death cannot be found following the postmortem examination.

Where a narrative verdict fits in: Sometimes, the coroner may decide that, instead of the suggested “short form” verdicts (e.g. “Natural Causes”, etc) he/she will use alternative wording that, on the evidence before him/her, he believes better explains the way in which the death occurred. This is called a “Narrative Verdict.”

If the family is unhappy with the service received from the coroner: In the first instance they should set out their concerns in writing and send it to the coroner for his/her personal attention. In the event that they are concerned with the results of a case then they may have to seek advice as to how to appeal. This may be both complicated and expensive as it may entail an application to the High Court. [See additional note below taken from the latest Coroners Charter.]

The role of the Chief Coroner: In September 2012, the Chief Coroner of England and Wales took up his appointment. This is a new appointment created under the Coroners and Justice Act 2009. He has a number of responsibilities including the supervision of training for coroners and their staff, issuing guidelines and directions to provide consistent practice, giving directions in certain cases and generally providing leadership and a figurehead to the Coroners Service in England and Wales. His office is located at: Chief Coroner’s Office, Judicial Office for England and Wales, 11th Floor Thomas More Building, Royal Courts of Justice, London WC2A 2LL. Telephone 020 7947 7048.

From the Coroners Charter:

If you are unhappy with a coroner’s personal conduct you should complain to the Office for Judicial Complaints (OJC). Examples of possible personal misconduct are using insulting, racist or sexist language in court, failing to fulfil judicial duties or inappropriate behaviour outside the court such as a coroner using his or her judicial title for personal advantage or preferential treatment. There is no charge for complaining to the OJC and it can be done online via the OJC website: Alternatively, you can download the OJC complaints form and send it to the OJC by fax, post or email.  You can also complain by letter or email. The OJC’s contact details are: Office for Judicial Complaints, Steel House, 11 Tothill Street, 3rd Floor, 3.01-3.03, London, SW1H 9LJ. Tel: 020 3334 0145.  Fax: 020 3334 0031. Minicom VII 020 334 0146 (Helpline for the deaf and hard of hearing).

If you wish to complain about the personal conduct of a deputy coroner or assistant deputy coroner you should write to the coroner whom the deputy or assistant deputy supports. If you think that the coroner’s handling of a complaint about his or her deputy or assistant deputy amounts to personal misconduct of the coroner then you can refer the matter to the OJC.  However the OJC cannot deal with the actual complaint against the deputy or assistant deputy coroner.

Further information about complaints about coroners can be found on the OJC website:

If you believe the service you have received falls short of the standards set out in this Charter or wish to complain about the way an investigation was handled or about the conduct of coroners’ officers, you should first write to the coroner. You should copy your letter to the local authority which funds the service. (The coroner’s office will be able to advise you of the relevant local authority, if you are unsure of this.)

If dissatisfied with the council’s response the next step is to complain direct to the local authority (the Local Government Ombudsman) at, or by calling 0300 061 0614 or 0845 602 1983. Alternatively a complaint may be made in writing to: The Local Government Ombudsman, PO Box 4771, Coventry CV4 0EH.

There is no charge to complain about the standard of service from a coroner’s office.

Michael Burgess OBE