Claire Dawson
When a person dies, there are specific procedures that must be followed, and these can vary depending on the circumstances of the death. In some cases, hospitals may need to call a coroner, especially if the deceased was not under medical care or seen by a doctor within a certain time frame before their death. The coroner's role is to determine the identity of the deceased and the cause, timing, and location of their death. They may order a post-mortem examination or an inquest to gather the necessary information. While most deaths are not investigated by coroners, they are called upon when deaths are sudden, violent, or unnatural, or if the cause is unknown. The coroner's jurisdiction and qualifications vary across different regions, and their involvement in the death certification process is crucial for registering a death and facilitating funeral arrangements.
| Characteristics | Values |
|---|---|
| Who is a coroner? | A coroner is a specialist judge who investigates deaths. |
| When is a coroner involved? | When a death is sudden, violent, or unnatural, or the cause is unknown. Also, when a death occurs in police custody or prison. |
| Who can report a death to a coroner? | Police, hospital doctors, out-of-hours doctors, GPs, and the governor of a prison. |
| What happens after a coroner is informed? | The coroner may decide to conduct a post-mortem examination, either at a hospital or a mortuary, and/or hold an inquest to determine the identity of the deceased, how, when, and where they died. |
| What is an inquest? | An inquiry into the circumstances of a death, open to the public and the media. It is not a trial, and its purpose is to gather evidence and provide details for death registration. |
| What happens after the coroner's investigation? | The coroner releases the body for burial or cremation and provides necessary certificates, such as the 'Pink Form - form 100B' and 'Certificate of Coroner - form Cremation 6'. |
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What You'll Learn
When to call a coroner
A coroner must be notified of a death in the following circumstances:
- When a death is sudden with unknown causes, violent, or unnatural. This includes deaths that may be linked to an accident, suicide, poisoning, or industrial injury.
- If the deceased was not seen by a doctor within 14 days of death, or if the doctor is unwilling to determine the cause of death.
- When a death occurs in police custody or prison.
- When the deceased was in detention under the Mental Health Act, even if the death was due to natural causes.
- If the death is linked to medical treatment, surgery, or anaesthesia.
- If the death is linked to drugs or medications, whether prescribed or illicit.
- If there are any suspicious circumstances or a history of violence.
- If the death is linked to the person's occupation, such as exposure to asbestos.
In some cases, a coroner's involvement may be required for deaths related to mass disasters or for overseeing the investigation and certification of deaths within their jurisdiction. It is important to note that not all deaths will require the involvement of a coroner, and the majority of deaths are certified by a doctor.
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Post-mortem examinations
In most cases, if the deceased was under medical care or had been examined by a doctor within a certain timeframe before their death (this timeframe varies from 14 to 28 days depending on the source), the doctor can issue a death certificate, and a coroner's involvement is not necessary. However, if the death occurred without prior medical attention or if the doctor is unable or unwilling to determine the cause, the coroner will step in to investigate.
The coroner's jurisdiction includes overseeing deaths related to mass disasters, those that occur in custody, and deaths that may be linked to medical treatment, accidents, drugs, or suspicious circumstances. The coroner's team, often consisting of individuals with medical or paramedical backgrounds, carries out the investigation on the coroner's behalf.
During a post-mortem examination, the coroner may collect tissue samples and slides for further analysis, and these can be retained for future use with the coroner's consent. Once the examination is complete, the coroner releases the body for the funeral and provides the necessary forms for cremation or burial. If an inquest is required, the coroner will set a date once their investigation is concluded.
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Inquests
An inquest is an inquiry into the circumstances of a death. The purpose is to identify the deceased person and establish how, when, and where they died, providing the details required for official registration. While an inquest may involve witnesses, it is not a trial, and the coroner does not decide or apportion any civil or criminal liability, guilt, or blame. Coroners decide who should be witnesses and give evidence.
A coroner investigates and decides whether an inquest is necessary when a death is sudden, violent, or unnatural, or the cause is unknown. They also investigate deaths that occur in police custody or prison, or deaths that may be linked to medical treatment, surgery, anaesthesia, accidents, drugs, medication, suicide, suspicious circumstances, or a person's occupation. If a doctor is available to issue a death certificate, an inquest is usually not required.
The coroner will release the body for burial or cremation once their investigations, including any post-mortem examinations, are complete. If no inquest is required, the coroner will send a form to the registrar, stating the cause of death.
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Death certification
In the United States, when a death certificate must be completed, it is typically the responsibility of the physician to fill it out. However, in instances where a crime or foul play is suspected, the medical examiner or coroner takes responsibility. In rare cases, such as the death of a hospice patient, a nurse practitioner may fill out the death certificate if a physician is unavailable. The death certificate can be subject to amendment, and lawsuits against those who sign it are extremely rare.
In the UK, the death certification system in England and Wales has been largely unchanged for over 50 years and is overdue for reform. The Coroners and Justice Act 2009 allows NHS bodies in England and Wales to appoint medical examiners, who are senior medical practitioners providing independent scrutiny of causes of death. These medical examiners will soon become a statutory requirement prior to the registration of all non-coronial deaths in England and Wales.
A coroner investigates and certifies deaths related to mass disasters, violent or unnatural deaths, deaths with unknown causes, deaths resulting from poisoning or industrial injury, and deaths in police custody or prison. When a death is suspected to be sudden, with an unknown cause, violent, or unnatural, the coroner decides whether to hold a post-mortem examination and, if necessary, an inquest. The coroner will gather information to determine whether a death was due to natural causes and if a doctor can certify the medical cause of death. If a post-mortem examination is ordered or an inquest is held, the death cannot be registered until the coroner's investigation is completed.
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Coroner's jurisdiction
A coroner's jurisdiction is limited to determining who the deceased was and how, when, and where they died. They are independent judicial office holders who can be removed from office only by the Lord Chief Justice. While coroners are appointed and paid by local authorities, they are not employees of those local authorities.
In the UK, a coroner's jurisdiction includes overseeing the investigation and certification of deaths related to mass disasters that occur within their jurisdiction. A coroner's office typically maintains death records of those who have died within their jurisdiction. The qualifications required of a coroner vary significantly between jurisdictions. For example, in Tasmania, the Chief Magistrate acts as the state coroner, whereas, in Brazil, only physicians can perform the duties of a coroner.
In England, a coroner's jurisdiction includes ordering a post-mortem examination and, if necessary, an inquest. An inquest is an inquiry into the circumstances of a death, and it is open to the public and the media. It is not a trial, and it is not for the coroner to decide any question of criminal or civil liability or to apportion guilt or attribute blame. Coroners decide who should take part as witnesses at an inquest. Witnesses will first be questioned by a coroner, and there may be further questions by 'properly interested people' or their legal representatives.
A death should be reported to a coroner when:
- The cause of death was sudden, violent, or unnatural, such as an accident or suicide.
- The person died before a provisional diagnosis was made, and the general practitioner is not willing to certify the cause.
- The patient died as a result of the administration of an anaesthetic.
- The deceased was not seen by a doctor or any other medical professional within 14 days of death.
- The death is deemed violent or unnatural, the cause is unknown, or it occurred in police custody or prison.
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Frequently asked questions
Hospitals are not required to call coroners when people die. However, if the death was due to unnatural causes, such as an accident, or if the deceased was not seen by a doctor within 14 days of death, then a coroner may be called to investigate the cause and manner of death.
Coroners decide whether to perform a post-mortem examination when the death is suspected to be sudden with an unknown cause, violent, or unnatural.
An inquest is an inquiry into the circumstances of a death. It aims to determine who the deceased person was, how, when, and where they died. It is not a trial and is open to the public and the media.
Yes, if the deceased has been under medical care or seen by a doctor within 14 days of death, the doctor can typically issue a death certificate. However, if the doctor is unwilling to make a determination, the coroner will investigate and provide the certification.
The coroner will gather information and investigate whether the death was due to natural causes. If a post-mortem examination is ordered, funeral arrangements should not be finalized until the coroner authorizes the release of the body.
