What will a coroner do when a death is reported?

The coroner’s investigation into a death

The coroner may decide that a post mortem examination and inquest are not necessary because the cause of death is clear and there is a doctor who can sign the Medical Certificate of the Cause of Death (MCCD) to that effect. In such cases, the coroner will advise the Registrar of Births and Deaths that no further investigation is needed.

The coroner may ask a pathologist to examine the body and carry out a post mortem examination (also known as an autopsy). If so, the examination must be undertaken as soon as possible.

The 2009 Act introduces the new concept of the coroner’s “investigation” into a death. An inquest is only part of the investigation, and may not be necessary. A lot of the coroner’s work actually takes place before any formal inquest hearing. It also allows the coroner time to consider whether the duty to hold an inquest applies in a particular case, rather than having to open an inquest as soon as practicable.

Preliminary inquiries

The new statutory regime permits a coroner to make preliminary inquiries to see whether there should be an investigation. The coroner may make whatever inquiries seem necessary.

Purpose of the investigation

The coroner’s investigation will seek to determine:

  • who the deceased was; as well as
  • where, when and how the deceased came by his or her death.

In deaths where Article 2 of the European Convention on Human Rights applies, the question of “how” is treated more broadly and is to be read as including:

  • by what means and in what circumstances the deceased came by his or her death.

If the coroner decides to investigate the cause of death he must identify the deceased’s personal representative or next of kin and inform them of the decision


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