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Understanding Coroners and Investigations

Overview of coroners and investigations

At Headstone we are generally dealing with unexpected deaths where most of the people using our platform have died far too soon and potentially in tragic circumstances that would normally warrant investigation by the coroner. We thought it would be helpful to set out what a coroner is and when they might be used because in all likelihood, any death from a Headstone member is going to be something that they would look into.  So, what would happen to you and what would your family be going through?

What exactly is a coroner?

A coroner is an independent judicial office holder who is appointed by a local authority (council) within the coroner's jurisdiction.Coroners are usually lawyers, but they can also be doctors.

What are coroners responsible for?

Coroners look into reported deaths if they have reason to believe that:  

  • the death was violent or unnatural;  
  • the cause of death is unknown; or  
  • the deceased died while in prison, police custody, or another type of state detention, such as an immigration centre, or while detained under the Mental Health Act 1983.  

When a death is reported to a coroner, he or she must determine whether an investigation is necessary; if so, they then investigate to determine the identity of the person who has died; how, when, and where they died; and any information required to register the death; and uses information discovered during the investigation to assist in the prevention of future deaths where possible.

A death may be referred to the police for investigation on behalf of a coroner in some cases. This could be because the police have expertise, such as in the case of a car accident, or because criminal activity was involved in the death. Other organisations, such as a hospital, the Health and Safety Executive, the Prisons and Probation Ombudsman, the Care QualityCommission, or the Independent Police Complaints Commission, may be required to conduct their own investigation into the death in some cases. This investigation is usually conducted first, and the results are given to the coroner so that he or she can use the information in the inquest.

What exactly is a coroner's officer?

Coroners' Officers work for coroners and communicate with bereaved people, as well as police, doctors, witnesses, mortuary staff, hospital bereavement staff, and funeral directors. The majority of Coroner'sOfficers are civilians, but some are also Police Officers.

Some Coroners have other titles on their staff, such as‘Secretary’ or ‘Clerk to….’

Who pays for the coroner's services?

The costs of providing a local coroner's service are usually borne by the local government. In some areas, the coroner's officers are employed by the local police force. The Officers' work, however, is always done under the authority of the Coroner, who is independent of both the LocalAuthority and the local police force. About half of all fatalities are reported to the Coroner.

When should a death be reported to a coroner?

In certain circumstances, registrars of births and deaths, doctors, or the police must report deaths to a coroner. These include cases in which it appears that:  

  • no doctor saw the deceased during his or her most recent illness
  • although a doctor attended the deceased during his or her most recent illness, the doctor is unable or unavailable, for whatever reason, to certify the death
  • the cause of death is unknown
  • the death occurred during an operation or before recovery from the effects of an anaesthetic
  • the death occurred at work or elsewhere  

If a death of this nature has not been reported to the coroner, someone may file a report on their own. This should be done as soon as possible, and preferably before the funeral. The coroner will then inform them of the course of action he or she intends to take.

When the deceased's own doctor or a hospital doctor who has been treating him or her during the final stages of an illness is able to diagnose and certify a natural cause of death, the coroner is not called in.

When a death is reported, what will a coroner do?

A coroner may conduct preliminary inquiries to determine whether to investigate the death. In some cases, such as a discussion with the deceased's doctor, those inquiries reveal that the deceased died as a result of a known and natural disease or condition, with no unusual circumstances. TheCoroner will not need to conduct any further investigations, and the doctor will be asked to sign a Medical Certificate of the Cause of Death (MCCD). In these cases, the coroner will notify the registrar of births and deaths that, despite being informed of the death, no further investigation is required. Your family can then make an appointment with the registrar to have the death registered. However, the Coroner may decide that a suitable practitioner, usally a pathologist, should examine the body and conduct a post-mortem examination to help determine the cause of death.

Examining the Body

A representative of your family may be asked to identify the body formally. The architecture of the buildings where viewings take place varies, and in some cases, they will see the person through a glass window rather than being in the same room. If, for example, your body has been damaged as a result of a traffic collision, this will be explained to your family sensitively, and they will be given the option of seeing you or having some other form of identification used if possible. 

When a deceased person's doctor or a hospital doctor certifies the cause of death without referring it to a coroner, the death can be registered by the registrar of births and deaths, who issues the death certificate. A doctor may occasionally consult with the Coroner about a case.As a result, the Coroner may decide that he or she does not need to investigate because the death was caused by natural causes. As a result of that discussion, the Doctor or the person in charge may be able to issue the MCCD, and the coroner will issue a certificate to the registrar stating that the Coroner is not required to investigate the death.

If the Coroner decides to investigate the death, theRegistrar of Births and Deaths must wait for the Coroner's investigation to be completed before registering the death. This investigation may take some time, for example, if an inquest is held so it is always best to contact theCoroner's Office before making any funeral arrangements. In most cases, the decision to investigate will not impede funeral arrangements or benefit processing.

The Coroner has the authority to issue a certificate confirming the fact of death and, if known, the medical cause of death.Although this cannot be used to register the death, it can be used to help with estate administration.


The work done by the Coroner is very important but can sometimes lead to delays that mean your family have to wait before being able to lay you to rest. We understand the utmost is always done not to impose unnecessary delays but in these circumstances when the Coroner is involved the death is always more likely to be unexpected and warrant a review to help or protect others. There is always plenty of support for families during this difficult time though and we hope that your family will not have to ever go through but if you understand a little more about it then perhaps it might help should you ever be involved. And if it’s you we lose then hopefully this article is of some comfort that well trained and experienced people will look after your body and most importantly, your family as they step through this traumatic process. But please use Headstone, because you could make all this a lot worse by leaving an administrative and financial mess too.  

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