Categories
Judiciary Law Legal Analysis Legal Professionals

What is a Coroner ?

Coroner

A coroner is an independent judicial officer responsible for investigating sudden, violent or unexplained deaths.

The office of the coroner was formally established in 1194, originally as a form of tax gatherer. In the centuries since this has evolved and now the role of the Coroner is to investigate deaths if they have reason to suspect that;

  • The death was violent or unnatural; or
  • The cause of death is unknown; or
  • The deceased died while in state detention.
Coroners – Courts & Tribunals Judiciary

Governed by the Coroners and Justice Act 2009 overseen by the Chief Coroner, their work meticulously establishes who died, how, when, and where, without assigning blame. This preventive role aids in avoiding future incidents and provides closure to bereaved families.

Operating across 74 local areas, coroners blend legal and medical expertise to maintain public trust. They also conduct Treasure inquests under the Treasure Act 1996, safeguarding archaeological heritage.

Each coroner area is led by a Senior Coroner. Some local authorities also appoint one or more Area Coroners to support the Senior Coroner in addition to the appointment of a number of Assistant Coroners.

The Ministry of Justice (MoJ) publish Annual National Statistics on deaths reported to coroners, including inquests and post-mortems held, inquest conclusions recorded and finds reported to coroners under treasure legislation.

Also published by the MoJ is the Guide to coroners statistics which provides a background overview of coroners, focusing on concepts and definitions published in Ministry of Justice statistics. It also covers policy background and changes, statistical publication revision policies, data sources, quality and dissemination.

The Chief Coroner’s Role

The Chief Coroner Her Honour Judge Alexia Durran is the judicial head of the coroner system, providing national leadership for coroners in England and Wales. The role of Chief Coroner was only established in 2009 and the first appointment in 2010.

The appointment of the Chief Coroner is made by the Lady Chief Justice in consultation with the Lord Chancellor.

Key duties of the Chief Coroner :-

  • Provide support, leadership and guidance for coroners in England and Wales;
  • In conjunction with the Judicial College, put in place suitable training arrangements for coroners and coroners’ officers;
  • Approve coroner appointments;
  • Keep a register of coroner investigations lasting more than 12 months;
  • Publish Prevention of Future Death reports and responses;
  • Monitor investigations into the deaths of service personnel;
  • Exercise global case management powers (including directing transfers of inquests between coroner areas in certain circumstances, and requesting the Lord Chief Justice and Lord Chancellor to appoint judges in certain high-profile or complex inquests); Provide an annual report on the coroner system to the Lord Chancellor, to be laid before Parliament;
  • By convention, the Chief Coroner also sits in the High Court hearing some of the most important judicial and statutory review cases concerning coroners.

Appointment and Qualifications

Coroners are appointed by their local authority, with consent from the Lord Chancellor and Chief Coroner. These permanent roles last until age 75, ensuring stability and independence from external influences.

Candidates require at least five years’ experience as solicitors, barristers, or registered medical practitioners specialising in pathology or forensics. This expertise enables effective navigation of legal-medical intersections. The Chief Coroner’s oversight guarantees selections prioritise integrity and competence.

The Investigation Process

Investigations start with the coroner assuming temporary custody of the body, ordering a post-mortem—often forensic for suspected unnatural causes—to establish the medical facts. Family input on cultural sensitivities is sought, with non-invasive options like CT/MRI scans available to lessen distress.

An inquest follows if required: a public hearing, ideally within six months, reviewing evidence from witnesses, reports, and experts.

Article 2(2) of the European Convention of Human Rights (ECHR) inquests are enhanced inquests held in cases where the State or ‘its agents’ have ‘failed to protect the deceased against a human threat or other risk’ or where there has been a death in custody. Cases where the deceased has been under the care or responsibility of social services or healthcare professionals are also often included in this category of inquest.

‘Jamieson’ and ‘Middleton’ inquests as they are sometimes known, consider neglect on the part on of an individual, and system neglect, under Article 2, respectively.

Juries are used in custody deaths, notifiable accidents, or police actions, issuing verdicts like ‘accidental’, ‘misadventure’, ‘unlawful killing’, or narratives without blame.

Treasure inquests similarly assemble experts to verify criteria, notifying the British Museum for preservation.

Powers and Impact

Coroners possess extensive statutory powers to ensure thorough and transparent investigations. They can summon witnesses to give evidence under oath, compel the production of documents or objects, and even enter premises if necessary for inquiries.

Inquests may be suspended or adjourned pending criminal proceedings, public inquiries, or the gathering of evidence from abroad, preventing overlap and preserving evidential integrity.

Practical support includes issuing interim death certificates to facilitate urgent administrative needs, such as insurance claims or funerals, while full registration awaits conclusion. Delays in investigations, those surpassing 12 months, are reported to the Chief Coroner, who can intervene to expedite processes and maintain efficiency.

The Ministry of Justice have produced ‘A Guide to Coroner Services for Bereaved People’

Contact the Chief Coroner’s Office
Royal Courts of Justice
London
WC2A 2LL

Email: [email protected]

Coroners’ Society of England & Wales

The Coroners’ Society of England and Wales is the principal professional association and representative body for coroners operating in England and Wales.

Membership is primarily restricted to serving coroners, area coroners, and assistant coroners with corresponding membership open to equivalent judicial office-holders abroad.

Check out the related articles on the Government Legal Department (GLD), Attorney General, Solicitor General, Lady Chief Justice, Lord Chancellor, Justice Secretary, Rule of Law, Open Justice, Law, Is the Law Black and White ?, Government Legal Department, Crown Prosecution Service (CPS), Abuse of Process, What Does Lady Justice Symbolise ?, McKenzie Friend, Can a Judge Direct a Jury to Find a Defendant Not Guilty ?,Law Society, Law Commission, McKenzie Friend Right of Audience, Solicitors, Solicitors Regulation Authority, Barristers, Bar Council of England and Wales, Bar Standards Board, R v Sussex Justices, Police Impartiality and the highly questionable Sussex Family Justice Board.

The Ministry of Injustice is not the Ministry of Justice nor is it affiliated in any way with the justice system, legal profession, police or any other law enforcement agencies.

Latest Articles ↓

Most Popular ↓

You should always seek formal legal advice from a qualified and reputable lawyer (solicitor or barrister).

There are a number of links to Free and Paid For Legal Resources and Legal Organisations on the Free Legal Advice , Legal Aid and Pro Bono pages.

[post_title] was last updated on the 2nd June 2026

By Dom Watts

Dom Watts founded the Ministry of Injustice in July 2021. Dom is an IT Professional with 30+ years experience in Tier 1 Banking, Government, Defence, Healthcare and Global Blue Chips. Dom has no legal training and is not a lawyer but has previously consulted for a Magic Circle Law Firm. You can find Dom on X or Google.

Dom Watts publishes the Ministry of Injustice as a citizen journalist. The journalism exemption is detailed in the Data protection and journalism code of practice published by the ICO and Section 124 of the Data Protection Act 2018.

Section 2 of the Defamation Act 2013 sets out the defence of truth. Section 3 of the Defamation Act 2013 sets out the defence of honest opinion. Section 4 of the Defamation Act 2013 sets out the defence of public interest. Section 8 of the Defamation Act 2013 sets out the single publication rule.

Section 4a of The Limitation Act 1980 defines the time limit for actions for defamation or malicious falsehood as one year from the date on which the cause of action accrued.

Article 10 of the Human Rights Act 1998 gives the right to freedom of expression. "This right shall include freedom to hold opinions and to receive and impart information and ideas without interference by public authority and regardless of frontiers."

"Free speech encompasses the right to offend, and indeed to abuse another." - Para 43 Scottow v CPS [2020] EWHC 3421 (Admin)

"Free speech is a fundamental common law right" - Para 21 R v Shayler [2002] UKHL 11 [2003] 1 AC 247 per Lord Bingham and Para 42 Phillips -v- Secretary of State for Foreign, Commonwealth and Development Affairs [2024] EWHC 32 (Admin)

Dom is a member of The Free Speech Union

“A key issue here is the need to distinguish between conduct which, however objectionable, does not justify invoking the criminal law and conduct which crosses the line and results in criminal liability" - Para 31 R v O’Neill [2016] EWCA Crim 92 [2016]

“Harassment is generally understood to involve improper oppressive and unreasonable conduct that is targeted at an individual and calculated to produce alarm and distress” - Para 38 R v O’Neill [2016] EWCA Crim 92 [2016]

"The behaviour said to amount to harassment must reach a level of seriousness passing beyond irritations, annoyances....The gravity of the misconduct must be of an order which would sustain criminal liability" - Paras [40-44] Hayden v Dickenson [2020] EWHC 3291 (QB)

"If you tell the truth, you don't have to remember anything"

In 2002 Dom Watts was an unlikely consumer champion. The dad of three from Croydon took on the power and might of Kodak – and won...Dom on BBC Working Lunch

Rule of Law - Open Justice - Policing By Consent