The role of the coroner

The role of the coroner is to investigate deaths in accordance with Section 1 of the Coroners and Justice Act 2009.  Namely – that the coroner is made aware that a death has occurred within the coronial jurisdiction, and there is ‘reason to suspect’ that the death was:

•    violent or un-natural
•    the cause of death is unknown
•    the death occurred while the deceased was in custody or otherwise in state detention.

Not all deaths referred to HM Coroner’s Service Cumbria will result in a statutory coronial investigation.  

A death may be referred to HM Coroner’s Service by the police, the medical examiner, hospital bereavement services, medical practitioners based in the community and in some cases, the registrar.  

When a death is referred to the coroner – some basic information about the death and surrounding circumstances will be provided to the coroner.  Such as, the identity of the person who has died (the deceased) and the next of kin details. 

A member of the coroners team will contact the deceased’s next of kin following the referral to ascertain/confirm: 
•    the deceased’s details, such as their full name, date of birth, address, occupation, marital status and medical history.
•    the circumstances surrounding the death and establish if there are any issues and concerns regarding the death.
Once a death has been referred to HM Coroner’s Service Cumbria, the cause of death must be established and enquiries will be made of the deceased’s medical practitioner.  

Where the deceased’s medical practitioner can issue a medical certificate which states the cause of death – which is natural, this will be issued by the medical practitioner and there will be limited coronial involvement.  

If this is not possible, the coroner must establish the cause of death and arrangements will be made for a post mortem to be undertaken as part of the coroners preliminary enquiries.  If a post mortem reveals a natural cause of death, the coroner will notify the bereaved family and registrar so that arrangements will be made for the death to be registered.

If however, a post mortem reveals an un-natural cause of death, the statutory duty to investigate the death in accordance with section of the Coroners and Justice Act 2009 above will be triggered, and an inquest will be scheduled to take place.  

When an inquest is scheduled to take place, the matters to be ascertained at the hearing, are set out in section 5 of the Coroners and Justice Act 2009.  Namely;
•    who was the deceased 
•    how, when and where the deceased came by his or her death.
These are known as the ‘four statutory questions’.  
A coroner cannot express an opinion on any other matter.  
The coroner must also establish the particulars required in accordance with the Births Deaths and Registration Act 1953 so that the death can be registered.

Where an inquest is required, a death can only be registered after an inquest has concluded.  However, the coroner can provide an ‘interim certificate of fact of death’ which can be used for probate, other legal/financial affairs, and to prove the fact of death.   

At the inquest, the coroner will make a number of determinations and findings in relation to the circumstances surrounding the death.  However, these determinations and findings cannot be framed in a way that apportions blame or suggests any criminal/civil liability on the part of a named individual.  

An inquest is a fact-finding inquiry and not a civil or criminal trial.