Personal Injury, Serious Injury & Clinical Negligence

A Guide To Coroners and Inquests

The Charter for Coroner Services and The Coroners and Justice Act 2009

Each year 493,200 deaths are registered in England and Wales. Approximately 46% of these deaths will be reported to a coroner. Of these cases approximately 13% (30,700) will go on to be the subject of an inquest. For families and friends of the deceased persons who are subject to an inquest the process can be complicated and not easy to understand. Up until now the law in relation to inquests has been set out in the Coroners Act 1988 and there has been little uniformity between the coroner’s offices in England and Wales.

On 12 November 2009, The Coroners and Justice Act 2009 received Royal Assent; however, many of the provisions contained within the Act have still not been implemented. Following public consultation in July 2010 and again in September 2011, the government has now published the new Charter for Coronial Services. As proposed in the consultation, this is being published in a single booklet combing the Charter for Coroner Services with the Guide to Coroners and Inquests. The Charter came into effect on 27 March 2012. To access the Charter please see below links:

The Charter sets out for the first time the standards that bereaved families and others can expect from the coronial service in England and Wales. It is hoped that the Charter together with the implementation of the majority of the provisions in Part 1 of the 2009 Act will help to ensure much more consistent standards in the coroner services provided throughout England and Wales.

The Coroner

A coroner is an independent judicial office holder, appointed and paid by the local authority in the area in which they work. A coroner must be either a lawyer or a doctor of not less than 5 years experience. Although independent from local council, coroners are appointed by the local authority. Each coroner must pick a deputy coroner. The deputy coroner must also be a lawyer or doctor of not less than 5 years experience. Although coroners’ posts must be advertised, in practice, the majority of coroners will have acted as a deputy coroner in the first instance. At present there is no upper age limit for coroners. Under the 2009 Act there is much more focus on governance of coroners and there will be an upper age limit of 70 years.

It is intended under the 2009 Act, that a Chief Coroner will be appointed. The Chief Coroner will be appointed by the Lord Chief Justice with agreement of the Lord Chancellor. As part of the Chief Coroner’s responsibilities they will be responsible for training and regulation, investigations, preparation of annual reports to the Lord Chancellor and maintaining a register of investigations lasting more than 12 months old. They will also have to consent to all new coroner appointments.

Reporting a death to a coroner

At present, Registrars of Births and Deaths, doctors and the police will report deaths to a coroner in certain circumstances. These include instances where the cause of death appears to be unknown, where the death was sudden or unexpected, where the death occurred during an operation or before recovery from the effects of anaesthetic and where the death occurred in prison, police custody or other state detention. Less than 50% of deaths are ever reported to the coroner. However, once a death has been reported, the registrar of births and deaths will not issue a death certificate until the coroner has concluded their investigations.

The coroner, either personally or through their deputies, must be available at all times for deaths to be reported. In the majority of cases the coroner will decide that the cause of death is evident and natural and there will be a doctor who can sign an medical certificate of cause of death (MCCD) to that effect. In these circumstances the coroner will advise the Registrar of births and deaths that no further investigation is needed.

Under the 2009 Act the intention is for each Trust or board to appoint medical examiners. Medical examiners must be registered medical practitioners with over 5 years experience and must have been in practice within the previous 5 years. The medical examiner will be responsible for approving all death certificates completed by the attending practitioners. The medical examiner will be the main point of contact to the coroner in that area and will be responsible for reporting deaths to the coroner where appropriate.

Post-mortem Examination

In approximately 40% of the cases reported to the coroner, the coroner will order a post-mortem examination to be carried out. The coroner is not required to obtain the consent of the relatives for a post mortem examination; however, they must inform certain persons of where and when the post mortem will be carried out. Under the 2009 Act relevant persons such as family members can appeal to the Chief Coroner if they believe that the decision to proceed or not to proceed to a post-mortem was incorrect.

In the event that a post mortem is carried out, if following receipt of the post-mortem report, the coroner is satisfied as to the cause of death and has no reason to suspect that the person died a violent or unnatural death or that they died in police custody, then they will release the body for the funeral and send a form to the Registrar of Births and Death so that the death can be registered. Again under the 2009 Act relevant persons can appeal the coroner’s decision to the Chief Coroner.

Inquests and Appeals

In approximately 13% of deaths reported to the coroner, the coroner will order an inquest.

An inquest is a limited, fact-finding inquiry to establish who has died and how, when and where their death occurred. Under the 2009 Act the matters to be ascertained at the inquest are slightly wider then set out in the previous legislation and include ascertaining in what circumstances the deceased came by his or her death.

The inquest is not a process to apportion blame to any party or parties. When the coroner’s investigations are complete they will hold the inquest. Inquests are usually held without a jury. However, if the death occurred in prison or at work, then a jury will be required. Under the 2009 Act this will be extended to include deaths in all state detention and any deaths caused by notifiable accident, poisoning or disease. The coroner will decide what evidence is required and who should be called to give evidence.

Possible conclusions as to how the death occurred are set out in the Coroners Rules 1984. These include: natural causes, accident or misadventure, suicide, unlawful killing and where there is insufficient evidence for any other verdict an open verdict will be recorded. A coroner may also chose to give a narrative verdict.

If during the course of an inquest it becomes apparent that something could be done to prevent other deaths, a coroner may announce at the end of the inquest that they intend to draw this to the attention of the person or organisation that may have the power to take action. This power is set out under Rule 43 of the Coroners Rules 1984. The person receiving such a report from the coroner must provide a written response. Under the 2009 Act the Chief coroner will be responsible for collating ‘Rule 43s’ and responses.

All inquests must be held in public and therefore both members of the public and journalists may attend.

At present if, following the inquest, any party wishes to appeal the coroner’s decision then they must apply for judicial review of the coroner’s decision. Under the 2009 Act appeals against a coroner’s decision will be made direct to the Chief Coroner.

The personal injury and clinical negligence departments at Clarke Willmott frequently advise clients in relation to inquests. If you require any further information regarding inquests, please contact Lee Hart or John Boyle.