The death of a loved one is something that all of us will likely experience during our lifetimes, and dealing with that loss can be challenging at the best of times. Sometimes however, the death of a loved one is referred to a coroner which can often cause further upset and distress.

Here at Sydney Mitchell, we have put together some notes and guidance to help you understand the process and to provide you with some practical advice when a coroner is involved.



A coroner is an independent judicial office holder, appointed by a local authority (council) within the coroner area. Coroners are usually lawyers or doctors with a minimum of five years' experience. The Chief Coroner heads the coroner service and gives guidance on standards and best practice nationally.


A inquest is a legal investigation into a death, conducted by a coroner, where:

  • the death is unexpected, such as the sudden death of a baby (cot death);
  • the death is violent, unnatural or suspicious, such as a homicide, suicide or drug overdose;
  • the cause of death is unknown; or
  • the deceased was in a state of detention at the time of their death (e.g. police custody or detained in hospital under the Mental Health Act 1983).

The purpose of an inquest is for the coroner to determine four key facts: who the deceased was, and where, when and how that person came by their death.


A post-mortem examination, also known as an autopsy, is the examination of a body after death. The aim of a post-mortem is to determine the cause of death. A coroner’s post-mortem examination is independent and is carried out by a suitable medical practitioner who specialises in understanding the nature and causes of disease (such as a pathologist).

The post-mortem takes place in an examination room that looks similar to an operating theatre. During the procedure, the deceased person's body is opened and the organs are removed for examination. A diagnosis can sometimes be made simply by looking at the organs. However, some organs may have to be examined under a microscope and these investigations can take several weeks to complete.  Subject to the families’ wishes, body tissue taken for analysis at post-mortem is usually either reunited with the body, or disposed of in a respectful manner.

A family cannot usually object to a post-mortem being carried out. There are non-invasive post-mortems which utilise medical scanning equipment to internally examine a body, but these are only available from private companies and there are costs to these which the family must pay. Sometimes these scans fail to show an identifiable cause of death, meaning that a “normal” post-mortem is still necessary.


Once a post-mortem has been completed, the pathologist will prepare a report for the coroner to review. As soon as the coroner confirms that the post-mortem is complete and that no further investigations are necessary, the body can be released back to the family so that the funeral can be arranged.

If the post-mortem report reveals that the person died due to natural causes, the coroner may decide that no formal inquest is necessary and will complete the necessary paperwork to ensure that the death can be formally registered with the Registrar of Births, Deaths and Marriages.

If the post-mortem report reveals that the person died a violent, unnatural or unexpected death (or if the cause of death is still unknown), the coroner will arrange for an inquest to take place. A Pre-Inquest Review may be arranged to determine what witnesses to call to the inquest, and what evidence should be considered.


An inquest is always held in public, usually in a special courtroom or other designated building.

It is important to stress that inquests are neutral fact-finding investigations into a death, and are not about allocating blame, and there is no prosecution and defence. However, interested persons may be represented by lawyers if they wish, or can choose to represent themselves.

As part of the lead-up to the inquest, the coroner may request statements from family, doctors or anyone who may have relevant information about the deceased or the death, and those written statements can often be accepted at the inquest without an individual having to give evidence in court. If a witness is summoned to attend the inquest, their evidence is given under oath.

The coroner will ask questions of each witness. After that, any interested person (or their lawyers) can ask more questions of each witness, but those questions must be relevant to the inquest and its scope, and must not, for example, be about liability or blame.

Once all the evidence has been heard, the coroner may invite the family or their legal team if they want to make any submissions or observations that will guide the coroner in making a decision.


At the end of the Inquest, the coroner will sum up all of the evidence he/she has heard, and can give the following conclusions (previously called “verdicts”) about the death:

  • Natural causes;
  • Accident or misadventure;
  • Suicide;
  • Narrative (which allows the coroner to describe briefly the factual circumstances by which the death came about);
  • Unlawful killing (or lawful killing);
  • Miscellaneous (drug dependence, industrial disease, stillbirth);
  • Neglect; or
  • Open (meaning that there is insufficient evidence to determine how the death came about – the case is left open in case further evidence appears).

If the family wish to challenge the coroner’s conclusion, this can only be done by way of judicial review in the High Court, and there are strict timescales within which a challenge must be brought.

Once the inquest has been concluded, the coroner will formally register the death with the Registrar.


As well as their investigative duties, coroners also have a responsibility to send reports to persons, organisations, local authorities or government departments where the coroner believes that action should be taken to prevent future deaths.

Following the inquest, and depending on the facts, the coroner may send a report to that person/organisation that has the responsibility to take appropriate steps to reduce the risk of future deaths, and under the law, they have a mandatory duty to provide a written response within 56 days.

These reports and written responses are now routinely saved and published on, meaning that future unnecessary deaths are avoided and that there is full accountability and transparency.


If a coroner determines that an inquest must take place, it can be many months before a final hearing can take place (depending on the complexity of the legal and medical issues involved). However, coroners aim to complete most Inquests within 12 months of the initial report of the death, and the coroner’s office will keep families updated if there are any delays that are beyond their control.

In the meantime, the coroner can issue a Certificate of Fact of Death which can be used to notify local authorities/government agencies/insurance companies/banks etc and obtain a Grant of Probate/Letters of Administration.


  1. You should nominate one family member to be the sole representative that will co-ordinate with the coroner’s office on behalf of the family;
  2. Contact the coroner’s office at the earliest opportunity with any concerns that the family may have. You may wish to write a letter or email setting out these in detail. This will ensure that the coroner can focus on the issues that are important to the family, and determine what issues are to be considered as part of the coroners’ investigation;
  3. Make a note of, and keep in touch with, the coroner's officer who will be your main point of contact with the coroner’s office, and will keep you updated as to how the investigation is proceeding;
  4. You may wish to ask the coroner to disclose certain documents to you. You should be aware that some documents can be distressing (e.g. the post-mortem report), and therefore you should think carefully about what you want to see;
  5. An inquest can be very difficult for some people to deal with emotionally. However, for others it can be a helpful part of their grieving process. You may wish to ask a close friend to support during this time and to attend with you at the inquest for moral support;
  6. Sections of the press and the media can sometimes be present at the inquest, as the hearing itself is held in public and the press may wish to report on the inquest if there are any unusual aspects. It is important to stress that you don’t have to talk to the media if you don’t want to. However, some families want to tell their story. You should take some time to reflect upon the conclusion of the inquest before speaking with the media;
  7. Finally, if you need someone to talk to, the Samaritans can be contacted from any phone at any time of day on 116 123 or via email at


Legal Aid is rarely available for Inquests, so you may have to pay for a lawyer to attend and represent you at an inquest. We at Sydney Mitchell can offer you advice as to the best method of funding for carrying out the inquest – whether it be on a private paying basis or under a “no win-no fee” agreement as part of a personal injury or clinical negligence case.

There may be a negligence claim relating to the death (such as a road traffic accident or a mistake arising from medical treatment). We can offer help and advice on whether a claim can be made and what steps can be taken.

For more information or legal help and advice when dealing with Coroner's cases, please contact Adam Hodson 0121 698 2200

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