When a death is referred to a coroner, families can find themselves facing an unfamiliar and often frightening process at an already devastating time. The involvement of a coroner does not imply that anything has gone wrong or that anyone is to blame. In many cases it is simply a legal requirement that certain types of death be investigated to prove the facts. Understanding what a coroner does, when an inquest is needed, and what the process involves can help families navigate this stage with greater clarity and confidence.
This guide explains the role of the coroner in England and Wales, the circumstances in which a death must be referred, what happens during an inquest, and what this means for the funeral and the death certificate.
What Is a Coroner?
A coroner is an independent judicial officer whose primary responsibility is to investigate deaths that are sudden, unexpected, violent, or of unknown cause. Coroners are appointed by local authorities and are typically legally or medically qualified, often holding both qualifications. They are independent of the police, the NHS, and the government, and their role is entirely focused on setting up the facts surrounding a death rather than attributing blame.
The coroner's authority covers England and Wales. Scotland has a separate system under the Procurator Fiscal, and Northern Ireland runs its own coroner service. This guide focuses on the process in England and Wales.
When Is a Death Referred to a Coroner?
A death must be referred to the coroner in several circumstances. The referring party is usually a doctor, a hospital, or the police. The most common reasons for referral include:
• The cause of death is unknown or cannot be certified by a doctor
• The person had not been seen by a doctor within 28 days before their death
• The death was sudden or unexpected
• The death occurred during or shortly after a surgical procedure or medical treatment
• The death may have been caused by an accident, industrial disease, or work-related injury
• The death was violent, unnatural, or occurred in suspicious circumstances
• The death occurred in custody, including in prison or a police cell
• The death may have been caused by self harm
It is important to understand that a referral to the coroner does not automatically mean that an inquest will follow. In many cases the coroner can set up the cause of death without holding a formal inquest, and the process is resolved quickly.
What Happens After a Death Is Referred?
Once a death is referred, the coroner will review the circumstances and decide how to go ahead. In straightforward cases where the cause of death can be established through medical
evidence, the coroner may issue a certificate known as a pink form or Form 100B, which allows the death to be registered and the funeral to go ahead without the need for a postmortem or inquest.
In other cases, the coroner may request a postmortem examination, also known as an autopsy, to figure out the cause of death. A postmortem is a medical examination of the body carried out by a pathologist. The family does not need to consent to a postmortem ordered by the coroner, though they do have the right to be informed of the date and to have their own doctor or medical adviser present if they wish.
Following a postmortem, if the cause of death is showed and no further investigation is needed, the coroner can release the body for the funeral to continue and issue the necessary documentation for registration. If the postmortem does not prove the cause of death, or if the circumstances of the death require further examination, the coroner may open an inquest.
What Is an Inquest?
An inquest is a formal public hearing held by the coroner to set up the facts surrounding a death. It is not a trial, and it does not look to prove criminal liability or civil responsibility. Its purpose is to answer four specific questions: who died, where they died, when they died, and how they came by their death.
Inquests are held in public and families have the right to attend. Legal representation is also permitted, and in some cases, families may wish to instruct a solicitor to be their interests at the inquest, particularly where the circumstances of the death are complex or disputed. Legal aid may be available in certain cases.
The coroner may sit alone or with a jury. A jury inquest is needed in specific circumstances, including where the death occurred in custody, in circumstances that may affect public health or safety, or where the death was caused by an accident at work. The jury's role is to return a conclusion about the circumstances of the death, which the coroner records as part of the inquest record.
How Long Does an Inquest Take?
The time from referral to the conclusion of an inquest varies depending on the complexity of the case, the availability of evidence, and the workload of the coroner's office. A straightforward inquest may be completed within a few months. Complex cases, particularly those involving medical negligence, deaths in custody, or multiple deaths in the same incident, can take longer and in some cases may not conclude for a year or more.
Families are entitled to receive updates on the progress of the inquest and should be kept informed of any hearings or pre inquest reviews that take place. If you are concerned about delays, you can contact the coroner's office directly or seek advice from a solicitor.
What Conclusions Can a Coroner Return?
At the conclusion of an inquest, the coroner or jury will return one of several conclusions. The most common conclusions in England and Wales are:
• Natural causes: the death resulted from a natural illness or condition
• Accident or misadventure: the death was the result of an unintended accident
• Suicide: the deceased took their own life, determined on the balance of probabilities
• Unlawful killing: the death resulted from the unlawful act of another person
• Lawful killing: the death resulted from a lawful act, such as a lawful use of force
• Industrial disease: the death was caused by a disease contracted through work
• Narrative conclusion: a short factual statement setting out the circumstances of the death where no single short form conclusion adequately describes what happened
The conclusion of an inquest is not a finding of criminal guilt and cannot be used as such in later legal proceedings, though it may inform decisions about whether to pursue civil claims or criminal investigations.
What Does This Mean for the Funeral?
One of the most pressing concerns for families when a death is referred to a coroner is what it means for the funeral. In most cases the coroner will release the body as soon as the postmortem has been completed and the cause of death shown, allowing the funeral to go ahead. The funeral does not need to wait for the conclusion of any later inquest.
However, if the death is the subject of a criminal investigation, the body may be kept for longer as evidence. In these circumstances the coroner or the police will keep the family informed of when the body is likely to be released.
The death cannot be formally registered until the coroner has issued an interim certificate of the fact of death or the inquest has concluded. This interim certificate allows the family to deal with certain practical matters, such as notifying relevant authorities and accessing some financial accounts, while the investigation is ongoing.
How The Farewell Guide Can Help
At The Farewell Guide, we understand that navigating the coroner process can feel overwhelming, particularly when you are already dealing with loss. Our support centre offers free guidance on every aspect of what to do after a death, including circumstances where the death has been referred to a coroner. Our free funeral planning tool and funeral director search allow families to find trusted local funeral directors who have experience of working alongside coroners and managing the practical arrangements during what can be a prolonged and uncertain period. Visit www.thefarewellguide.co.uk to access our full range of free resources.