Reporting deaths to the coroner
Summary
If a death occurs in a violent or unnatural manner, in custody or state detention, or without certain cause, the coroner has a duty to enquire into the death. This factsheet sets out the role of the coroner, the reporting process and what will happen once you have reported a death to the coroner.
The coroner
The coroner is usually a lawyer, but may be a doctor. A few coroners have dual qualifications. Coroners are independent judicial officers appointed by local councils, but holding office under the Crown and currently reporting only to the Lord Chancellor.
Coroners have a duty to enquire into a death if the body of the dead person lies within their jurisdiction, or coronial district, and the death was violent, unnatural or sudden with cause unknown. This includes deaths that follow an accident. The coroner’s enquiries may involve holding an inquest. Once a death has been referred to the coroner, it cannot be registered until the coroner’s enquiries have been completed and a death certificate issued and provided to the Registrar of Births and Deaths.
The coroner's office
The coroner is supported by a deputy coroner, and either the coroner or the deputy will be available at all times to deal with enquiries about inquests and postmortem examinations. The coroner’s officers (often serving police officers) receive the reports of deaths and make enquiries on behalf of the coroner.
Reporting deaths to the coroner
The coroner will usually request a postmortem examination if there is uncertainty over the cause of death
Deaths should be referred to the local coroner if there is reason to suspect that the deceased has:
- Died a violent or unnatural death (including accident or suicide)
- Died and the cause of death is unknown
- Died while in custody or otherwise in state detention
- Died as a result of a medical mishap, etc (this list is not exhaustive).
If you are unsure about whether or not to report a death, contact the coroner’s officer, who will be able to advise you whether a formal report is appropriate.
In order to complete the Medical Certificate of Cause of Death (MCCD), the doctor must have attended the patient within the 14 days leading up to the death, or seen the body after death and be sufficiently familiar with the patient to be sure of the cause of death. If the medical cause of death is reasonably clear but there is still some uncertainty, or the doctor who attended the patient in his last illness is not immediately available to sign the MCCD, the matter can often be resolved by a discussion with the coroner directly, or via the coroner’s officer. If satisfied that neither an inquest nor a postmortem examination is necessary, the coroner will issue Pink Form A, which allows the Registrar of Births and Deaths to register the death so that the deceased can be cremated or buried.
The coroner will usually request a postmortem examination if there is uncertainty over the cause of death.
If the practitioner performing the postmortem informs the senior coroner that, in their opinion, death was caused wholly or partly by the improper or negligent treatment of a registered medical practitioner or other person, that practitioner or other person must not make, or assist at, an examination under this section of the body, but is entitled to be represented at such an examination.
This subsection has no effect on a postmortem examination already made.
If the postmortem reveals that the death was not unnatural, the coroner will issue Pink Form B to the Registrar, which means that the death can be registered and the body released for cremation or burial.
However, if the coroner finds that the death was unnatural, an inquest will be held. This happens in about 12% of all cases referred to coroners. Individuals whom the coroner believes may be able to provide relevant information will be asked to submit a statement. Witnesses may be called to give evidence in person or required to submit written evidence to be presented at the inquest.
Duty to report deaths
There is now a statutory duty on all healthcare personnel to report a death.
The Lord Chancellor may make regulations requiring a registered medical practitioner, in prescribed cases or circumstances, to notify a senior coroner of a death of which the practitioner is aware. Primary Care Trusts (in England) and Health Boards (in Wales) must appoint persons as medical examiners.
There is also a common-law duty on all citizens to give information that may lead to the coroner holding an inquest, to establish the cause of death.
The General Medical Council states: “You must co-operate fully with any formal inquiry into the treatment of a patient ... You must disclose to anyone entitled to it any information relevant to an investigation into your own or a colleague’s conduct, performance or health. You must assist the coroner ... in an inquest or inquiry into a patient’s death by offering all relevant information. You are entitled to remain silent only when your evidence may lead to criminal proceedings being taken against you.”
You should not delay notifying the coroner of a death as this will lead to delays in the involvement of, for example, the police. It will also delay the registration of the death and the release of the body for either cremation or burial, adding to the distress of the bereaved.
The Registrar of Births and Deaths currently has a statutory duty to report certain types of deaths to the coroner – for example, where it appears that the death occurred during an operation, and deaths due to industrial disease.
Registration of a death
Before a death can be registered in England and Wales, there must be either a properly issued MCCD issued by a registered medical practitioner (the death certificate is issued by the Registrar of Births and Deaths) or a certificate from the coroner issued after appropriate investigations (see paragraph above).
If you are the attending medical practitioner in a patient’s last illness, you are required by law to sign a certificate stating the cause of death to the best of your knowledge and belief. This must be submitted to the Registrar of Births and Deaths. The certificate is a legal statement and therefore false or inaccurate statements could result in criminal charges. If you are unable to establish the cause of death, you should refer the case to a senior coroner.
Other functions of the coroners
The coroner must also be notified in every case when a body is to be taken out of England or Wales.
Coroners also currently have responsibility for all the treasure troves in their district, and anyone who acquires property in an object, and believes he has reasonable grounds for believing that the object is treasure, must notify the coroner within 14 days.
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