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Registering A Death

The Coroner


What is a Coroner?

It is in the general interest of the community that any sudden or unexplained death should be investigated. Coroners, who are experienced doctors or lawyers are responsible for investigating the circumstances surrounding any death which occurs under unusual circumstances, or is thought to be due to certain industrial diseases.


When is a death reported to the Coroner?

This happens when:

  • no doctor has treated the deceased during the last illness
  • the doctor attending the patient did not see the deceased within 14 days before death
  • the death occurred during an operation or before the recovery from the effect of an anaesthetic
  • the death was sudden and unexplained or attended by suspicious circumstances
  • whilst in the custody of the police or in prison
  • the death might be due to an industrial injury or disease, or to accident, violence, neglect or to any kind of poisoning
  • the death is subject to a DoLs order.(Deprivation of Liberty Safeguards)


The coroner may request that a pathologist performs a post-mortem examination of the deceased (an autopsy) in order to look for signs of disease or injury that may account for the death. The post-mortem examination will take place at either Manchester Royal Infirmary, Royal Oldham Hospital or Salford Royal Hospital depending on where the death occurred.

Additionally, a coroner may consider it necessary to hold a formal enquiry into the individual case, called an inquest.


What is the purpose of an inquest?

An inquest is a fact-finding enquiry, with the sole objective of determining the answers to the following questions:

  • Who is it that has died?
  • When and where did the death occur?
  • How did the determined cause of death come about? What was the nature of the death, and what was the nature of the contributory events preceding it?


An inquest is usually opened in the first few days following the death, in order to record the fact of death, and is then subsequently adjourned. The inquest is re-opened and completed once all necessary police enquiries and coroner's investigations have been completed. An inquest is not a criminal trial. It is an inquiry into the facts surrounding a death. It is not the job of the coroner to place blame or responsibility for the death, as a trial would do. However, the coroner does have the power to investigate not just the main cause of death, but also "any acts or omissions which directly led to the cause of death".


What are the possible verdicts of an inquest?

  • Natural causes (i.e. organic disease)
  • Accident or misadventure
  • Suicide
  • Unlawful or lawful killing
  • Industrial disease
  • Open verdict (a result of insufficient evidence for a death to be categorized into any other group)


Sometimes the inquest will show that something needs to be done to prevent a recurrence. The coroner can draw attention to this publicly and will write to someone in authority about it, for example the council or a government department.


Are witnesses called to an inquest?

The coroner decides who to ask and the order in which they give evidence. Any person who wants to give evidence can come forward at an inquest without being summoned by the coroner, but the evidence must be relevant to the inquest. A person who wants to give evidence should contact the coroner as soon as possible after the death.

The evidence of a witness may be vital in preventing injustice, and they may have to pay a penalty if they do not attend. A witness will normally receive a formal summons to attend the inquest. In certain circumstances, a signed statement or other document may be given in evidence.

Anyone who has "a proper interest" may question a witness at the inquest. They may be represented by lawyers or, if they prefer, ask questions themselves. The questions must be sensible and relevant. This is something the coroner will decide. There are no speeches. "Properly interested individuals" would normally include:

  • A parent, spouse, child, and anyone acting for the deceased
  • Any person who gains from a life insurance policy on the deceased
  • Any insurer having issued such a policy
  • Anyone whose actions the coroner believes may have contributed to the death
  • The chief officer of the police force
  • Any person appointed by a government department to attend the inquest
  • Any other person the coroner determines to have a "proper interest"


Can a funeral be held before the completion of an inquest?

Under normal circumstances, it is possible to hold a funeral, with either a burial or a cremation, before the formal completion of the inquest. The coroner will issue the relevant documentation permitting the funeral director to undertake proper disposal of the body.

However, there may be some delays and restrictions in certain types of cases, particularly those relating to cases of unlawful killing, homicide, road traffic accidents etc. A coroner's officer and your funeral director will be able to advise you on the individual circumstances of your particular case.

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