The death has been referred to the coroner
In 2015 about 45% of deaths in England and Wales were referred to the coroner. One reason deaths are referred to a coroner is because the cause of death is not known, for example, someone who is apparently fit and well who collapses and dies in the street in spite of all efforts by bystanders and paramedics. The other reasons coroners have to be informed of a death are when it is thought the death may be unnatural in any way including due to an accident. It would also include anyone who has been detained on grounds of lack of mental capacity This would include patients in care homes, general hospitals and mental health institutions, especially if a Deprivation of Liberty (DOLS) was applicable.
An unnatural death includes any death that may have been brought about by the action of someone else e.g. murder or manslaughter but also if someone failed to take action that they should have done e.g. a health professional failed to give treatment correctly that resulted in the death of their patient.
Deaths soon after operations and other medical procedures are usually referred to the coroner in case something has gone wrong even if medical staff are not aware that there was a problem. Road traffic collisions and someone taking their own life are other examples of unnatural death.
Whatever the circumstances, you should give the coroner’s staff full and truthful information about the person who has died. You should also tell them of anyone else you think will have helpful information for the investigation, even if you are not personally on good terms with the other person or people. If there is an inquest later and you are asked to give evidence you will have to swear an oath to tell the truth. If you give different information to the coroner at that time it will be very embarrassing and if you lie in court you will be committing perjury and could be fined or be imprisoned.
The coroner and their team understand that you may be very distressed not just that someone close to you has died but possibly also in particularly difficult circumstances. It is their role to discover the truth about the death and you do not need to feel embarrassed at any of the information you may have to give them. They are not there to come to any opinion about you or the person who has died.
When a death is referred to a coroner, it is then the responsibility of the coroner to decide if they will investigate the death further and how they will carry out the investigation. In many cases the decision to investigate is obvious, e.g. someone involved in a traffic accident, but sometimes a doctor may speak with the coroner or coroner’s officer as they are unsure if the coroner needs to investigate or not.
Often, in these cases, the coroner will want their officer to speak with the immediate next of kin or the person who has been caring for the person who has died, to obtain their view of the illness and care that was given. If it is agreed that that the death was from natural causes the doctor will be allowed to complete a medical certificate of cause of death.
The coroner will normally issue additional documentation to inform the registrar of deaths that they have been informed of the death and no further investigation is necessary.
If a death has been notified to the coroner, it is always the coroner who has the authority to make decisions about what happens to the deceased person (has ‘jurisdiction’). In law, no-one can own the deceased person’s body but when the coroner is involved, their legal right to make decisions about the deceased person’s body takes priority over those of anyone else.
However if police are investigating the death because of a possible criminal act, the coroner will work closely with the police. Police may appoint a Family Liaison Officer to lead on communication with the bereaved family.
The coroner will take account of information from the police on whether a post-mortem examination is needed and what type of examination and also when the deceased person can be released for a funeral to be arranged.
Usually you will be told by the doctor, hospital bereavement staff or police that the coroner will be informed of the death. You can also expect that they will tell you how to get in touch with the coroner’s office and when they are most likely to contact you.
If family were not present at or near the time of death, the coroner’s office will attempt to trace you and may ask for the assistance of the police to break the bad news to you.
Whenever possible the coroner’s team will want to speak to the nearest next-of-kin at a very early stage of the investigation as you may have important information about the person who has died, such as any medical conditions for which they are being treated (if it is not known who their doctor is) and aspects of their lifestyle which may be relevant such as if they regularly drank large amounts of alcohol or used non-prescribed drugs. Other information such as relationship difficulties or a recent redundancy and money concerns may be relevant if it is thought the person may have taken their own life.
Anyone can inform the coroner of a death if they have concerns about a death which they believe a coroner might need to investigate. However if you do have concerns that a death might be suspicious in any way the best course of action is to inform the police as soon as possible. Police officers are the best qualified to start investigating immediately if necessary and to make secure any possible crime scene or other evidence.
The coroner is informed about the majority of deaths by police officers and doctors as they are the people either present or have the information which enables them to give the coroner the information they need to make a decision about whether to investigate a death. Doctors have a legal duty to inform the coroner if they believe a death should be referred.
Coroners are described as judicial officers, i.e. in some ways they are like judges but they have a particular responsibility which is the investigation of any death which is brought to their attention. This information pathway describes when and why coroners become involved after the death and what that may mean for all the other practical matters you have to cope with.
All coroners appointed now are trained lawyers and some have also trained as doctors. A senior coroner is responsible for a particular area of the country (the entire province in the case of Northern Ireland) and have assistant coroners to support them. Coroners’ officers work under the direction of a coroner and carry out much of the day to day investigation of a death and are usually the people who have most contact with bereaved families. There may be other staff such as administrators, secretaries or clerks who may answer telephones or speak with you if you have to visit the coroner’s service or attend court.
Coroners are completely independent of all other organisations to enable them to investigate any death, whatever the circumstances.