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Referral to a Coroner

A coroner’s job is to ensure that as far as possible the cause of death is known and to investigate violent or unnatural deaths. If a doctor certifies a death then the coroner does not need to be involved, but this can only happen if the doctor is certain of the cause and has also attended the deceased within the fourteen days prior to death and there were no unusual circumstances. Deaths must otherwise be reported to the coroner and where death occurred in the following circumstances:

  • As a result of deliberate or accidental self harm e.g... suicide, drug abuse, neglect
  • As a result of neglect when a duty of care exists, for instance social services, care homes, parents of children under 18, children looking after elderly parents
  • An unanticipated death of a child
  • If violent crime was involved
  • As a result of an accident
  • During or shortly after detention by the authorities e.g.. police, customs or under the Mental Health Act
  • As a result of something the Police either did or failed to do
  • As a result of treatment or lack of treatment by doctors or medical staff
  • As a result of present or past employment e.g. accidents or industrial diseases
  • If the GP cannot identify a cause
  • As a result of childbirth or abortion
  • As a result of a specified disease e.g. MRSA
  • When death occurred overseas and the body is repatriated. See Deaths Abroad

Although this is a long list, about 70% of deaths in the UK do not need to be reported to the coroner.

What the Coroner will do

Often the coroner will consult with the GP and if the GP is confident of the cause of death they may be allowed to issue the death certificate as normal. The coroner may, however, decide that a post-mortem investigation is needed to determine the cause of death. Unlike a post-mortem requested by a hospital doctor, relatives cannot object to one ordered by a coroner. If the post-mortem satisfies the coroner that death was due to natural causes then he will normally send a Form 100 directly to the registrar so that the death can be registered. If the body is to be buried the registrar will give you the form authorising this. If it is to be cremated then the coroner will give you the appropriate form.


If the post-mortem was inconclusive or if death was not by natural causes or needs investigating then the coroner will hold an inquest to determine the facts. An inquest is a public hearing and the spouse or civil partner of the deceased, their Personal Representatives and their next of kin will be informed. If a claim for negligence or compensation against a third party is a possibility then you should also have legal representation at the hearing. The coroner will not release the body for burial or cremation until the inquest in concluded.

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