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The Coroner

  • There are approximately 600,000 deaths per year in England and Wales
  • Cause of death is certified by the attending doctor in about 75% cases
  • Of 150,000 deaths referred to the coroner
    • 60% are referred by doctors
    • 38% by the police
    • 2% by the registrar of births, marriages and deaths
  • Initial investigations are conducted by Coroner's Officers
  • They are plain-clothed policemen
  • Death certificate may be issued after discussion with a Coroner's Officers
  • Coroners only hold inquest for about 10% of deaths that they certify

Referral to the coroner

  • A death should be referred to the coroner if:
    • The cause of death is unknown
    • The deceased was not seen by the certifying doctor either after death or within 14 days of death
    • The death was violent, unnatural or suspicious
    • The death may be due to an accident (whenever it occurred)
    • The death may be due to self-neglect or neglect by others
    • The death may be due to an industrial disease or related to the deceased employment
    • The death may be due to an abortion
    • The death occurred during an operation or before recovery from the effects of an anaesthetic
    • The death may be due to suicide
    • The death occurred during or shortly after detention in police or prison custody

Role of the coroner

  • Coroner's Act 1988 defines when an inquest should be held
  • Inquests are held in public and may involve a jury
  • Purpose of the inquest is to determine
    • Who is the deceased
    • How, when and where he died
    • Details of the cause of death
  • The coroner is not concerned with civil or criminal liability
  • Coroner may record the cause of death as
    • Natural causes
    • Accident / misadventure
    • Industrial disease
    • Sentence of death
    • Dependence on drugs or non-dependent abuse of drugs
    • Lawful killing
    • Open verdict
    • Want of attention at birth
    • Unlawful killing
    • Suicide
    • Still birth
    • Attempted or self-induced abortion


Milroy C M,  Whitwell H L.  Reforming the Coroner's Service.  BMJ 2003;  327:  175-176.

Powers M J.  The coroner's inquest.  Br J Anaesth 1994;  73:  78-82.

Rheinberg N.  The office of the coroner;  past, present and future.  Hosp Med 2002;  63:  454-455.

Samuels A J.  Coroners.  Med Leg J 2001;  69:  37-39.



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