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See Procurator Fiscal in Scotland
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This article presently only refers to the situation in England and Wales. See Wikipedia for other jurisdictions

Their role is to investigate certain types of death.

  • Violent or unnatural (violence is usually unnatural)
  • Sudden or of unknown cause
  • Death in prison or in custody, which includes deaths in secure psychiatric units
  • Industrial-related deaths

Approximately 40-50% of deaths are referred to the Coroner and, of that, 40-50% undergo an autopsy.


Primary Job

LogoKeyPointsBox.pngWho died, when, where and of what

The Coroner (French couronne,Latin corona, as in latin custos placitorum coronae (coronas), pleas of the crown [1]) holds an ancient judicial office that actually had an Anglo-Saxon role. When recreated by the Norman's the coroner upheld appropriate legal procedure in a number of areas of life which allowed lucrative taxation. This included presumed murder by Anglo-Saxon subjects of Normans, rights of the King such as washed up whales and treasure trove. Where the complex legal procedure was not followed, punitive fines could be imposed to raise money for the King's coffers (bypassing the more corrupt sheriffs). The area of responsibility of investigation of sudden deaths, originally raised revenue because an Anglo-Saxon community could be fined for any unexplained body which was assumed to be Norman if not identifiable as Anglo-Saxon.[2]

In modern times, the coroner will hold a legal qualification, a medical qualification, or both. His main role is to determine, in the case of deaths, who died, when, where and of what. Further reform followed on from Shipman.

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Reform of the Coroner in 2009 has aims:

  • Introduce a national coroner service for England and Wales, headed by a new Chief Coroner and in due course rationalisation to about 75 individuals.
  • Improve the experience of those bereaved people coming into contact with the coroner system, giving them rights of appeal against coroners' decisions and setting out the general standards of service they can expect to receive
  • Reduce delays and improve the quality and outcomes of investigations and inquests through improved powers and guidance for coroners, and the publication of statistics and reports to prevent deaths
  • Introduce a system – for deaths not investigated by the coroner – that enables independent scrutiny and confirmation of the medical cause of death in a way that is proportionate, consistent and transparent.


  • 871 and 910 First mention of the Coroner in the reign of Alfred the Great but function unclear.
  • September 1194 Hubert Walter, Chief Justiciar and Archbishop of Canterbury solves a taxation problem for Richard the Lionheart in every county of the King's realm shall be elected three knights and one clerk, to keep the pleas of the Crown[3]. He had inherited an organisational problem due to the unpopularity of sheriff's corruption, and indeed in 1170 Henry II's 'Inquisition of the Realm' had sacked all the sheriffs but matters were hardly perfect with their replacements who also diverted funds due to the crown. Richards ransom payments outstanding were partially solved.
  • 1200 Royal Charters created additional Coroners in the Boroughs and, where a Lordship replaced the King as the local law-giver (as in the Welsh marches), the "franchise" Coroner created
  • 1215 Magna Carta Chapter 24 "No sheriff, constable, coroner or bailiff shall hold pleas of our Crown"
  • 1284 Statute of Rhuddlan introduces the post to Wales
  • 1603 "the Crowner" of Shakespeare's Hamlet "But is this law? Ay, marry, is't crowner's quest law!".
  • 1836 First Births and Deaths Registration Act
  • January 1846 Sergeant William Payne forms the Coroners' Society of England and Wales[4]
  • 1887 Coroners Act of 1887 repealed much earlier legislation. Coroners main duties now determining the circumstances and the actual medical causes of sudden, violent and unnatural deaths for the benefit of the community as a whole.
  • 1988 Coroners Act 1988
  • 1996 Treasure Act confirms the historic duty to determine treasure trove
  • November 2009 Coroners and Justice Act (implemented on the 25th July 2013)
  • 2012 Office of Chief Coroner established

Coroners' Officers

Usually a retired or sometimes, and out-of-hours, a serving Police officer. They possess common sense, knowledge of procedure, no special medical knowledge to rely upon, and sometimes a desire for peace and tranquility. They are very useful, and quite powerful, as the Coroner's proxy.

Coroners' secretaries

Usually take messages but can be very useful. The Coroner may use such offices to ensure discussion takes place at third party distance so do not expect to report a death where your own actions could be examined by other parties directly to the coroner themselves. (perhaps a little like the Coroner's clerks originally established, although the analogy should not be taken too far as the coroner clerk was quickly abolished and replaced by 4 coroner's per county rather than 3 and a coroner's clerk.

Statements to the coroner

Expert statements

  • Not covered
    • Fees should have been agreed in advance
    • It is not unknown for the coroner to ask say a Hospital Trust involved in the care of the patient to provide an expert opinion on a issue relevant to the death, where of course the hospitals actions are not felt likely to have been the cause of death. Fees may not be claimable in such a situation, where the coroner has instructed the Trust, not a named expert directly.

Statements as a professional witness

  • Stick to the instructions received - usually a report is wanted from the medical record
  • Fees might not be able to be charged - clarify - for example when your Trust asks you to prepare the report
  • Specify the records you have available when preparing report
  • Stick to the facts
    • Explain jargon
    • Consider explaining what each medication is for
  • Dates and names should be without abbreviations
  • Do not to give an opinion outside of a factual opinion based on the written instructions and relevant written records available to you. For example if you were to learn that the patient had a high drug level measured after death but both the death and the level was not done while patient under your care, you should not comment. On the other hand if a blood test done as part of routine medical care in life, came back after death highly relevant to the death such as the results of a blood culture you must mention this. However if a coroner, as sometimes happens, releases the pathologists cause of death to you it can be helpful to the coroner, if as sometimes happens they have released the pathologists cause of death to you
  • Your defence organisation or at a pinch your employers legal team can advise you on a statement and most certainly should be contacted if you sense that your professional conduct or competence might be called into question. Obviously this should not be necessary in the majority of cases where an extract from the medical records is requested and your role is peripheral to the death.

Attendance at an inquest

Expert attendance

  • Not covered
    • Fees should have been agreed in advance

Attendance as professional witness

  • You will be issued with a summons. It is contempt of court not to respond/appear. Review the case to ensure you have a good guess why you have been summoned. Any hint of unhappiness of relatives with care should by now have resulted in you taking appropriate advice.
  • Increasingly travel expenses etc are not being settled by coroners courts routinely - enquire and get the forms filled in at the time- for example if you are representing your employer the expenses are often now regarded as theirs to bare
  • You will be asked to make an oath or affirmation
    • Probably best to be consistent as to which you take - bible one week and no bible the next might raise eyebrows
  • Identify yourself and professional office
    • Usually this will be prompted
  • Stick to the facts when questioned, relevant to the question. Listen to the question and if unclear do not hesitate to ask for clarification. Answer as concisely as possible. If you do not know, say so or ask to refer to the original records if appropriate.
    • If you have made a statement you will probably have to read it out but that is up to the coroner, some just ask you questions based on this, others ask their questions after.
    • Questions may also be asked by a member of the deceased’s family or a legal representative. In the case of a jury inquest, members of the jury may also ask questions. Lastly, if a solicitor or barrister represents you, they may ask you further questions.
    • The coroner is obliged to exclude any inappropriate questions that are not relevant to the limited scope of the inquiry.
    • If you sense at this late stage that your professional conduct or competence is called into question, you may ask the coroner for an adjournment of the inquest and contact you defence organisation and/or your employing trust legal team, if not self employed, for advice.

Medicolegal guidance

Relevant Legislation

Coroners' Rules 1984

Govern the investigations by Coroners (rules reproduced here).

Coroner's Act 1988

Coroners and Justice Act 2009

See also

External links


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