Coroners are local independent judicial officers, appointed and paid for by the local authorities, who are responsible for investigating violent, unnatural deaths or sudden deaths of unknown cause and deaths in custody that are reported to them. It is in the general interests of the community that these deaths should be investigated and the role of the Coroner has adapted over the eight centuries since the office was formally established in 1194, from being a form of medieval tax gatherer to an independent judicial officer charged with the investigation of sudden, violent or unnatural death.

The coroner’s office responds to and investigates those deaths which have been referred to it for a wide variety of reasons. Just over one third of all deaths in England and Wales go via the coroner’s office to establish cause of death at the present time, something which seems at odds with the ‘extraordinary’ failure of NHS staff to report preventable death. In the wake of Dr Shipman’s conviction, there have been three separate inquiries looking at the way in which sudden death is investigated, and it is likely that there will ultimately be new legislation and subsequent changes to the way in which all deaths are investigated and the manner in which coroners carry out their duties.

An inquest is a legal inquiry into a death, held in public (sometimes with a jury) by the coroner. Only a coroner can order an inquest and relatives have no right to insist on one. Relatives may attend an inquest and ask questions of witnesses. They may ask a lawyer to represent them but there is no legal aid available for this. In England and Wales, an organisation called INQUEST may sometimes be able to arrange legal representation, either free or for a reduced charge. The inquest should provide more information about how and why the death took place and whether anyone else was responsible. In some cases, a criminal or civil prosecution may later take place. Once the inquest has been held the death can be registered and the funeral can take place (although in some cases the coroner may allow the funeral to go ahead before the inquest is over).

A draft coroners bill was published in June 2006, and was announced as part of the Coroner’s and Justice Bill in the 3 December 2008 Queen’s Speech. It aims to modernise the coroner service by providing a better service for bereaved people and making sure that investigations and inquests are more effective.

The Coroner’s workload has increased as a result of the Human Rights Act, Article 2: The Right to Life.

Related posts:

• Human Rights Article 2 and Medical Negligence Investigation.
• What is a Serious Untoward Incident?
• The Scale of the Stillbirth and Neonatal Death Problem in the UK.
• ‘Extraordinary’ failure of NHS staff to report preventable deaths.
• Another indication of poor NHS lesson learning.