What Do Coroners Actually Do?

A little while back (longer than I care to remember given how long it’s taken me to get around to typing this up) I had the chance to go to a teaching session given by my local coroner, explaining what it was that he and his colleagues did. This was a fab opportunity as previously their role that had always been a bit of a mystery.

What’s the role of the coroner?

Once a death has been reported to the coroner, it is up to them to decide whether the death is natural, unnatural or requires further investigations. The coroner is responsible for obtaining extra information for cases, including taking statements from medical staff and contacting families.

What’s a post-mortem and when and why do they happen?

Post-mortems involves the internal and external examination of a dead body. These are carried out by pathologists when the cause of death is unknown, sudden, unexpected or violent. This includes people who are in custody of some form or are undergoing medical treatment such as surgery.

While traditional post-mortems involve cutting the body to examine the inside, new techniques using MRI scanners can be used, especially in cases where religious belief prevent the normal procedures.

How many post-mortems are done?

In 2018, over 220,000 deaths were reported to the coroners in the UK, accounting for 41% of all registered deaths. Roughly 85,600 post-mortems were carried out, leading to just over 29,000 inquests. In Cornwall and the Isles of Scilly there were 3,000 reported deaths, 1,400 post-mortems and 350 inquests (Ministry of Justice, 2019).

Legal bits

Coroners are covered under the Coroner’s and Justice Act 2009 and they have no independent budget, relying on money from the local council and police to fund their investigations.

What the coroner really wants healthcare professionals to know:

  • Some deaths must be legally reported, that doesn’t necessarily mean anything untoward has occurred.
  • Documentation – always make sure documentation is clear and thorough as this will be one of the key things they look at during any inquests.
  • Treatment Escalation Plans – ensure these are up to date, and if a patient’s resuscitation status is discussed, but a TEP declined, this still needs to be documented.
  • If you’re called to the coroner, find out in what capacity. You could be called as a witness, or as an interested person and it can be more helpful to them if you’re more prepared.


Ministry of Justice (2019) Coroners Statistics Annual 2018. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/monthlyfiguresondea (Accessed: 11 June 2019).

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