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Overview of the coronial process in England and Wales

This overview of the coronial process in England and Wales is intended to help bereaved people, witnesses and others understand what the process is about. We also provide links to other information and resources here. 

People who come into contact with the coroner service following the death of someone close to them are usually unfamiliar with the coronial process, and can find it difficult to understand. This often leaves them feeling anxious and unprepared for the coroner’s investigation and (if there is one) the inquest.

Similarly, many individuals who are called to give evidence at an inquest (whether in a personal or professional capacity) have little or no prior understanding of what this involves. They may also be in need of information and advice.

For further information, see:

Coroners

Coroners are a special type of judge. Coroners are required, by law, to investigate deaths which are suspected to have been violent or unnatural, where the cause of death is unknown, or where the person died while being detained by the state – for example, in prison, by the police, in immigration detention or in a mental health care facility. 

Coroners’ investigations are carried out to answer four questions: who died, how they died (including the medical cause of death), when they died, and where the death occurred.  The final stage of some investigations is a fact-finding public hearing, which is called an inquest. 

The Chief Coroner is head of the coroner service in England and Wales and provides leadership and guidance for all coroners.

Coroners’ areas

Coroners are appointed by local authorities, with the consent of the Lord Chancellor. There are currently 77 coroners’ areas in England and Wales, each headed by a senior coroner. Links to all local coroner service websites are available here, and information on local coroner areas can be found on the Coroners’ Society website.

Usually, the investigation is carried out by a coroner in the area in which the body is lying, although in some cases there may be an agreement between coroners that the investigation will be transferred to a different area. A transfer to a different area may also be directed by the Chief Coroner.

Following a death outside England and Wales, a coroner’s investigation can only be carried out if the body is repatriated. In such cases, responsibility for the investigation will usually pass to the coroner’s area in which the deceased was living, or where their immediate family live. 

Coroners’ officers

In each area, coroners are supported by a team of coroners’ officers and other staff. Coroners’ officers are the main contact point for bereaved people and witnesses, and are usually responsible for gathering documents and information for the coroner. Most coroners’ officers are employed by the local authority, but some are employed by the police.

Interested persons

Interested persons are individuals who have certain rights during the coronial process. 

The coroner decides which individuals are interested persons. Usually, interested persons include close family members or other representatives of the deceased person. Interested persons may also include other individuals who were associated with the death in some way, such as health or criminal justice professionals who were involved with the deceased before the death. They may also include representatives of government departments and other organisations. 

The rights of interested persons include:

  • To be informed about the post-mortem examination, if one is to be carried out.
  • To be told about the dates and details of any inquest hearings.
  • To receive documents that may be considered at the inquest, including evidence from other interested persons (provision of this information is usually called ‘disclosure’).
  • To question witnesses at the inquest. 

Interested persons may also be asked to give evidence as a witness.

The process of investigation

Coroners’ investigations involve collecting and examining statements and other information relevant to the four questions of who died, and how, when and where they died. The investigation does not involve deciding if anyone is to blame for the death, or determining civil or criminal liability.

After a death is reported to the coroner, the coroner first, if necessary, carries out a preliminary inquiry and decides whether an investigation is required. If an investigation goes ahead, it usually includes a post-mortem examination. 

The inquest – which is usually a public hearing but may be conducted in writing (see below) – is the final stage of a coroner’s investigation. However, the investigation can be discontinued before the inquest if a natural cause of death has become clear and the coroner thinks it is not necessary to continue the investigation. An investigation cannot be discontinued before the inquest if the death was violent or unnatural, or if the person died in prison or another form of state detention. 

The investigation, including the inquest, should be completed within six months of the death being reported to the coroner, wherever possible. However, some investigations take much longer than this. The length of an investigation depends on the circumstances of the death, whether investigations are also being carried out by other organisations, the amount of information that the coroner needs to consider, and other factors. This means that sometimes there is a gap of many months or even years between the death and the final inquest hearing. 

The investigation process may result in delay to the funeral and administrative tasks that have to be carried out after a death. However, the coroner must release the body as soon as possible (after the post-mortem and any other examinations have been completed, where these are required), meaning that the funeral can usually take place before the inquest. To help with notifying the death, the coroner will issue an interim death certificate, also called a ‘Coroner’s Certificate of the Fact of Death’. The final death certificate can be obtained from the Registrar after the investigation is completed.

Article 2 investigations

Investigations which engage Article 2 are enhanced investigations by the coroner. These are held where the state failed to protect, or potentially failed to protect, the deceased person’s right to life under Article 2 of the European Convention on Human Rights (ECHR). 

In an inquest which engages Article 2, the coroner must consider not only ‘how’ the person died, but also the wider circumstances in which the death occurred.

The coroner usually decides if Article 2 is engaged before the final inquest hearing, at a pre-inquest review hearing. Unless it is established that the person died of natural causes, all deaths in prison or other forms of state detention are, in practice, subject to an Article 2 investigation. 

Post-mortem examinations

A post-mortem examination (sometimes known as an autopsy) is a medical examination of the body, or part of the body. It is carried out by a specialist doctor called a pathologist. 

The coroner may order toxicology (to check whether drugs or other chemicals have contributed to the death) or other tests to be carried out, in addition to or instead of a post-mortem. Some post-mortems involve scanning the body (using a CT or MRI scan) instead of an invasive or surgical procedure. The family should be informed of the time, date and place of the post-mortem and any other tests, and have the right to be represented at the post-mortem by a medical practitioner.

The body is usually returned to the family after the post-mortem has been completed. Sometimes, certain organs or tissue samples have to be kept for a period of time for further tests. If this happens the family must be kept fully informed. In rare circumstances, it may be necessary to keep the body for further examination.

The pathologist’s report on the post-mortem report forms part of the evidence considered by the coroner, including at the inquest if there is one. Interested persons, including the family, are entitled to request a copy of this report as part of disclosure.

Pre-inquest review hearings 

Pre-inquest reviews (also referred to as PIRs or PIRHs) are hearings held in the coroner’s court before the final inquest hearing. There may be one or more pre-inquest reviews. They are usually public hearings, meaning that anyone can attend. 

The purpose of pre-inquest reviews is for preparations to be made for the final inquest hearing. The coroner is likely to consider, for example, the scope of the inquest (that is, what specific isssues it will cover and whether it engages Article 2 of the ECHR); the evidence to be examined; which witnesses will be called to give oral evidence; and practical matters such as the likely length and date of the final inquest hearing. 

The inquest 

Unless the investigation has been discontinued, the inquest is the last stage of the coroner’s investigation. Most inquests are public hearings, conducted by the coroner in a coroner’s court. They can therefore be attended by anyone who wishes to do so. 

The inquest is a fact-finding process, which addresses the questions of who died and how, when and where they died. It is not a trial involving opposing ‘parties’, and does not assign blame or liability for the death.

At the inquest, the coroner (or jury, if there is one) hears evidence that will help them answer the questions about the death. This evidence may be partly or entirely in the form of written evidence which is read out in whole or summary to the court. Witnesses may be required to attend the inquest to give oral evidence. 

Inquest hearings may be as short as 30 minutes or less, or they may take place over days, weeks or months. Some inquests are attended by no one other than the coroner; in contrast, attendees at an inquest may include bereaved family, witnesses, lawyers, wider family and friends of the deceased person, journalists and others.

Since June 2022, coroners have been permitted to hold inquests in writing. This means that the inquest does not involve a public hearing in a courtroom. An inquest in writing can be held if the coroner notifies the interested persons that this is what they intend to do; there are no objections from the interested persons; there does not appear to be any prospect of disagreement over the inquest conclusion; and the coroner considers that no public interest would be served by a hearing.

Attending the inquest

Family members (whether or not they are interested persons) can choose to attend the inquest if they wish to. They can also bring people with them to give them support. 

Witnesses who have been called to give oral evidence are required to attend the inquest. Witnesses can bring other people with them for support if they wish.

In some coroners’ courts, volunteers from the Coroners’ Courts Support Service (CCSS) are available to provide support to family, other bereaved people and witnesses when they attend the inquest. 

Interested persons, witnesses, legal representatives, wider family and supporters can apply to attend the inquest remotely, via video or audio link. Coroners can permit remote attendance if this will improve the quality of witnesses’ evidence or is otherwise more convenient and practical than in-person attendance. 

At most inquests, the coroner gives family members the opportunity to say something about the person who died. This is sometimes called a ‘pen portrait’. The coroner may also allow a photo or video of the deceased person to be shown. 

Coroners’ courts vary widely in terms of their physical structure and layout, and the facilities available at the court. Some courts have a dedicated room for families to use during hearings. Information on courtroom access and facilities should be available on the local coroner service website: links to local services or from the coroner’s office. 

Family members and witnesses may wish to visit the court and observe other inquests before their own inquest, in order to familiarise themselves with the space and the process. 

Inquest hearings are open to the public and may be reported in traditional news media or on social media.  

Witnesses

Witnesses are individuals who provide information about the death. They may include family members, members of the general public, professionals (such as medical staff) who treated or had other dealings with the deceased before they died, the pathologist who carried out the post-mortem, and others.  

Witnesses usually provide information in the form of a written statement. Some witnesses are asked by the coroner to attend the inquest hearing (in person or remotely) in order to give oral evidence. At the inquest, witnesses have to take an oath or make an affirmation that they will tell the truth. They will then be asked to read through their witness statement or will be taken through their statement by the coroner. They may then be asked questions – first by the coroner and thereafter by interested persons or their lawyers.  

If a witness is asked to attend an inquest to give evidence and is not prepared to do so voluntarily, they may be issued with a witness summons and may face sanctions for non-attendance. Arrangements for a witness from a public sector organisation are usually managed through the organisation’s legal department.  

Witnesses are entitled to claim reasonable travel expenses from the local coroner service if they are called to give evidence at the inquest. 

Other evidence

In addition to written and oral statements from witnesses, many other forms of evidence may be examined at the inquest. These might include post-mortem reports and reports on toxicology and other tests; reports from other investigations into the death; medical records; photographs and CCTV footage; reports from expert witnesses such as medical consultants or forensic experts; and other kinds of documentation or physical items. 

Copies of evidence should be made available to interested persons (including family) in advance of the hearing; this is generally referred to as ‘disclosure’. 

Juries

A small number of inquests involve a jury. The inquest must be held with a jury if the death took place in prison or another form of state detention and was not from natural causes; if the death resulted from a police officer’s act or omission; or if the death was caused by a ‘notifiable accident, poisoning or disease’, such as a workplace accident. The coroner can also opt for a jury inquest if they deem there to be  another reason for doing so.

An inquest jury has between 7 and 11 members, who are randomly selected from the general public. They must listen to all the evidence presented at the inquest, and can ask questions of witnesses. After the coroner sums up the evidence and guides the jury on what issues they can consider, the jury must reach a conclusion on how the person died.

Like the coroner, the jury cannot assign blame or liability for the death. 

The inquest conclusion and record of inquest

At the end of the inquest, the coroner summarises the evidence. The coroner – or jury, if there is one – then gives their conclusion. This used to be called the ‘verdict’, and sets out who was the person who died, when and where they died, and the cause of death.

The conclusion on the cause of death might be ‘short-form’. Short form conclusions are: 

  • accident or misadventure
  • alcohol and/or drug related
  • industrial disease
  • lawful or unlawful killing
  • natural causes
  • road traffic collision
  • stillbirth
  • suicide
  • open (where there is a lack of evidence or the evidence was not conclusive).

The coroner or jury can also give a ‘narrative’ conclusion instead of, or in addition to, a short-form conclusion. This allows for more detail to be given about the facts surrounding the death. Narrative conclusions are more common in complicated cases, including those that engage Article 2.

The inquest conclusion is set out in writing in the ‘Record of Inquest’. A copy is provided to interested persons, including the family. Interested persons can also request the audio recording of the inquest hearing and any pre-inquest review hearings. 

After the inquest, the coroner notifies the Registrar of the cause of death, who can then issue the final death certificate.

Prevention of Future Deaths reports

The coroner must write a Prevention of Future Deaths report if an investigation makes them concerned that there is a risk of future deaths, and they consider that action could be taken to prevent or reduce that risk. The report should be addressed to those who the coroner believes have power to take such action, which might include individuals, organisations, local authorities or government departments or agencies.

Prevention of Future Deaths (also called Regulation 28) reports are public documents, usually published online on the judiciary website, along with the responses received, here. 

These reports identify matters of concern and recommend that action should be taken to reduce future deaths. They do not specify what the action should be. Recipients of reports must respond within 56 days. The response should set out how they propose to reduce the identified risks; if and how they have already done so; or the justification for declining to take action. Responses are usually also published on the judiciary website.

Legal advice and representation

Family members involved in the coronial process do not necessarily need legal advice or representation. However, if the inquest is dealing with complicated issues, or if public bodies attending the inquest are legally represented, the family may benefit from a lawyer’s help with preparing for the inquest, or from being legally represented at the hearing(s). 

Some legal aid is available to pay for legal help with preparation, or for legal representation at the hearing(s). This may depend on the individual’s financial situation. If the inquest engages Article 2 then legal aid is usually available for the family without means testing (that is, regardless of the family’s income).

If the family cannot access legal aid to pay for legal advice or representation, they may be able to get help for free (‘pro bono’) from a lawyer who wishes to volunteer their services. Sometimes legal help can be arranged on a ‘conditional fee’ or ‘no win no fee’ basis, if the family may make a civil claim after the inquest. Otherwise, legal help must be privately funded.

An inquest lawyer can help family members with such matters as identifying the family’s concerns; explaining and addressing legal issues; ensuring that important evidence is gathered and considered by the coroner; asking questions of other witnesses; and talking to the coroner on their behalf.

Public and corporate bodies usually have legal representation at inquests.

Complaints

In the first instance, complaints about any aspect of a coroner’s investigation can be made directly to the coroner or coroner’s officer. It may then be possible for the issue to be resolved informally. 

Complaints about the way an investigation was handled can be made to the local authority in which the local service is based. If the local authority does not provide a satisfactory response, it is possible to take the complaint to the Local Government and Social Care Ombudsman here. The Ombudsman can review how the complaint was handled, but not any decisions made by the coroner. 

Complaints about the way the coroner behaved can be made to the Judicial Conduct Investigations Office (JCIO). The complaint can be submitted online here. 

Challenging a coroner’s decision

The judicial decision of a coroner can be challenged by way of judicial review in the High Court, where a senior judge can review the lawfulness of the decision. This is a review of the way the decision was made, rather than the rights and wrongs of the conclusion reached. The judicial review usually must be carried out within three months of the original decision.  

Those who wish to consider bringing a judicial review case should seek legal advice. Guidance on the judicial review process is available here.

In some circumstances, the Attorney General can apply to the High Court for an inquest to be quashed or overturned, and a fresh inquest to be ordered. 

The medical examiner system

From 9 September 2024, all deaths across England and Wales that are not reported to the coroner will be reviewed by medical examiners.

Medical examiners, who are supported by medical examiner officers, are senior medical doctors. Their role is to review the cause of death recorded by the attending medical practitioner on the Medical Certificate of Cause of Death, for deaths where there has not been a referral to the coroner. Medical examiners are also expected to liaise with the coroner as required.

The purposes of the medical examiner system are to ensure independent scrutiny of non-coronial deaths; ensure appropriate direction of deaths to the coroner; improve the quality of death certification and mortality data; and provide greater transparency for bereaved people and the opportunity for them to raise concerns.  

Other investigations and legal proceedings

Some deaths may be the subject of various other investigations and legal proceedings in addition to the coroner’s investigation. 

Other types of investigation include, for example:

  • Patient Safety Incident Investigations (formerly serious incident reviews) of deaths in healthcare settings.
  • Investigations by the local police force professional standards department or the Independent Office for Police Conduct of deaths during or following police contact.
  • Prisons and Probation Ombudsman investigations of deaths of individuals in prison, secure training centres, immigration detention facilities and probation-approved premises; and, in some cases, of individuals recently released from detention.
  • Investigations of workplace deaths by local authority environmental health departments, the Health and Safety Executive and other regulators.
  • Learning Disability Mortality (LeDeR) reviews, which examine the health and social care received by people with a learning disability and autistic people who have died.
  • Investigations under the Maternity and Newborn Safety Investigation Programme (MNSI), which is hosted by the Care Quality Commission.
  • Service Inquiries into military deaths.  Depending on the setting and nature of the death, several different investigations may be carried out. 

If another investigation is being carried out, the coroner usually waits until that investigation is complete before holding the inquest. This can therefore lead to delays to the inquest – especially if several bodies are carrying out their own, separate inquiries into the death. Any other investigation reports are considered by the coroner as part of the evidence. 

If there is a criminal investigation into the death, the coroner opens the inquest and then suspends it until the criminal proceedings (including any trial) are complete. The coroner will then resume their investigation only if they consider there to be sufficient reason to do so; for example, if there are further facts to be examined. Otherwise, the coroner’s investigation will not be resumed. Occasionally, evidence heard at an inquest suggests that a crime may have been committed in relation to the death. In such a case, the coroner should pass the evidence to the Crown Prosecution Service, and criminal proceedings may follow. 

Where the family of the person who died wish to make a claim for compensation – for example, in relation to medical negligence – the civil proceedings usually follow the inquest. Evidence heard at the inquest may help family members to decide whether they wish to pursue a claim. There are strict time frames within which any such claims must be brought.

Judge-led inquests

In cases that are exceptional – because they are dealing with highly sensitive evidence or are especially high profile – an inquest can be conducted by a judge rather than a coroner. In such cases, the Chief Coroner requests the Lady Chief Justice, in consultation with the Lord Chancellor, to nominate a judge for the inquest.       

Public inquiries

Some deaths are investigated through a public inquiry. Public inquiries tend to have a broader scope than inquests, and are held where the deaths raise matters of wide public concern, or the evidence to be heard is highly sensitive and has a bearing on national security. A public inquiry can only be set up by a government minister, and is run by a government-appointed chair.

In some circumstances, an inquest can be converted into a public inquiry.