The role of the coroner

Any sudden death of unknown cause occurring in England and Wales (Scotland has a different system) will be referred to the local coroner. A coroner is a judicial officer, appointed to a specific territorial district, having responsibility for investigating those deaths that are sudden of unknown cause (as well as those that are violent or unnatural or occur in prison). The investigation that the coroner initiates may take a number of different forms but is likely to include discussions with and questions asked of the family; the local GP; those who were present when the death occurred; and any doctor or nurse who may have tried to revive the person. The investigation process will probably then include a post-mortem examination that will be made by a pathologist. The pathologist will seek to find a medical reason or explanation for the sudden death. This examination may entail a detailed examination of tissue taken from the body and specimens of blood and urine. The heart may also be carefully examined by a specialist to see if there is any obvious abnormality which may disrupt its proper function.

This whole investigative process may take some time and the coroner will probably decide that the best way forward is for an inquest to be conducted. This will give the necessary time and opportunity for the investigations to be fully completed. An inquest need not necessarily delay any funeral arrangements.

When the investigations are complete the coroner will hold the inquest (a public hearing), where those who can give information about the death will provide evidence. When all the evidence has been received, the inquest will be concluded by the coroner reaching a decision as to how the death came about – i.e. the medical cause of death, as well as the circumstances directly leading to it. This will all be recorded in a document ending with a conclusion or verdict. The coroner will then complete the death registration with the local registrar of deaths.


The role of the coroner’s officer

The coroner is supported by investigating staff, called coroners’ officers. They are either police employees or civilian staff trained to carry through the directions of the coroner. They will generally be responsible for taking the cases forward and be the person that the family should usually contact to ask questions and discuss the progress of a particular investigation. As necessary, they will keep the coroner informed and take their direction from the coroner.


The verdicts; and how each might be used in regard to young sudden cardiac death

At the inquest, the coroner will reach a verdict in accordance with the evidence that they have. If the evidence shows that the death arose from a naturally occurring disease process – even though it may have been one that was unknown about during life – the conclusion will probably be that the person died from Natural Causes.

If there was an unnatural element, as may be the case of (for example) a person who had a heart attack while swimming, then the verdict may be one of Accident; which might also be given if the person had been using or experimenting with drink or drugs.

An Open verdict may be given when the evidence does not demonstrate how the death came about and/or the intention of the deceased person is in doubt.

A verdict of Unascertained may be returned if the medical cause of death cannot be found following the post-mortem examination.

Sometimes, the coroner may decide that instead of the suggested “short form” verdicts (e.g. Natural Causes, etc) they will use alternative wording that, on the evidence before them, they believe better explains the way in which the death occurred. This is called a Narrative Verdict.


The role of the Chief Coroner

In September 2012, the Chief Coroner of England and Wales took up their appointment. This is a new appointment created under the Coroners and Justice Act 2009. The Chief Coroner has a number of responsibilities including the supervision of training for coroners and their staff; issuing guidelines and directions to provide consistent practice; giving directions in certain cases; and generally providing leadership and a figurehead to the Coroners Service in England and Wales.

The Chief Coroner’s office is located at: Chief Coroner’s Office, Judicial Office for England and Wales, 11th Floor Thomas More Building, Royal Courts of Justice, London WC2A 2LL. Telephone 020 7947 7048.