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The Role of the Coroner

The Involvement of the Coroner in Sudden Arrhythmic Death Syndrome (SADS)

Following the death of a loved one the Coroner does not wish to be perceived as heartless or distant from the bereaving family. As part of this, within Leicester, the family is asked how they wish the Coroner to refer to the person who has died. This is usually by their full or family name. This article relates strongly to someone who has died as a result of SADS and so can be young; therefore the person who has died will be referred to as "the child" rather than the more impersonal term "the deceased" which is often seen in many legal documents. It is acknowledged that SADS is not restricted to deaths in children, but can strike from the ages 12 – 35.

The Investigation Process

When a death is reported to the Coroner, if (s)he considers it is a natural cause of death and there is no other reason to investigate further and/or hold an inquest, the Coroner's officer will speak with the family to confirm they understand the death and do not dispute the cause of death. The Coroner will then send the necessary paperwork to the Registrar and instruct the reporting doctor to issue the "Medical Certificate Certifying Death". The Coroner will not be involved further.

If the cause of death is unknown the Coroner will request a post-mortem examination of your child. The Coroner's Officer will speak to you, ask you some brief details about your child and obtain information that will assist the Coroner and pathologist. You will be told when and where the post-mortem examination will take place and your right to have a doctor who treated your child in life to be present at the examination. This will be at your own expense and the doctor is not allowed to interfere with the examination. The post-mortem will be carried out the next working day or as soon as possible thereafter.

If a natural cause of death is established at the post-mortem examination and there are no reasons for the Coroner to investigate further or hold an inquest, the Coroner's Officer will notify you of this. The Coroner will instruct the release of your child to your nominated undertakers and send the necessary paperwork to the Registrar. This will usually be the same day as the examination or as soon as reasonably practicable thereafter.

If the post-mortem examination does not reveal a cause of death and further tests are required you will be notified what the tests are on the day of the examination and the nature of the tests. At the same time, you will be asked what your wishes are in relation to the tissue samples after they have been tested. You will be sent the necessary paperwork to complete, sign and return to the Coroner. If the further tests are histology and/or toxicology, your child can still usually be released to your nominated funeral directors following the post-mortem examination.

If any organs are needed for further tests you will be told which organs, and for how long they are likely to be retained. You will then be asked whether you wish the organs to be re-united with your child before release to you, or whether you wish to proceed with the funeral and make alternative arrangements for the retained organs. The Coroner's officer will discuss all of the options with you.

If after the further tests have been completed (which may take up to six months), the post-mortem examination reveals a natural cause of death, the coroner's officer will notify you of this and the Coroner will complete the necessary paperwork for the Registrar. If the organs have been retained and your wishes were for them to be re-united before the release of your child, the Coroner will instruct the pathologist of this and your child will then be released to your nominated undertaker. The Coroner will not be involved further.

If the cause of death is unnatural or remains unknown, the Coroner will open an inquest. If your child has not been released to you previously, the Coroner will instruct this now. The Coroner's Officer will notify you of the date of the opening.

The Inquest Process

A brief guide to the inquest process following the opening of the inquest. The inquest will be opened and adjourned for investigations to be conducted and reports to be prepared. Where reasonably practicable to do so the Coroner will set a final hearing date within six months of the date of death. The Coroner will review progress in the matter on a regular basis and all interested persons will be informed of decisions made at each review. Reviews are not public hearings and no information arising from them will be made public. They will not be listed on the Coroner's website. There are some cases that take a considerable amount of time to enquire into. All files are monitored regularly to ensure that all appropriate steps are taken and that delays are kept to a minimum. All those properly interested will be notified of the progress of the Coroner's investigations and the steps being taken. As soon as the Coroner is ready to hear the Inquest the Coroner's Officer will contact the interested persons to notify them of the date and time fixed for the hearing and the listing details will be published on the website.

Pre-inquest Review

If the inquest is complex, reports are not forthcoming, or it appears that the adjournment is continuing for too long, the Coroner will fix a date when all interested persons, including the family of the child and any legal representatives will be required to attend court for a formal hearing. This will be a public hearing. At a pre-inquest review, the Coroner will deal with any outstanding matters and will give such further directions as are necessary to prepare the case for a final hearing. Usually the Coroner, in conjunction with the family and legal representatives will, at the pre-inquest review, decide upon the scope of the inquest, the evidence to be heard and the witnesses to be called at the final hearing. The date for the final hearing will usually be set at this pre-inquest review. All interested persons will receive written confirmation of the date and this will be publicised on the website. Any properly interested person who wishes to inspect or receive copies of any statements or document to be considered at the Inquest may apply to the Coroner.

Final Hearing

This is the resumption of the adjourned Inquest and is a public hearing. When interested persons arrive at court, they will be shown around the court and given an explanation of what is to happen. Generally all witnesses will be in court during the inquest. The child's family and all other properly interested persons will have the opportunity to give evidence and to ask questions of the witnesses who are called. The Coroner will hear all the evidence and then make the findings of fact that are required; (s)he will announce their conclusion about the death (their 'determination' previously known as "the verdict").

After the Inquest

On conclusion of the inquest the next of kin will be provided with an explanation about how where and when a copy of the death certificate may be obtained. If the next of kin is not present a written explanation will be sent via post. If in the interest of preventing further fatalities the Coroner decides to report the matter to a relevant person or authority, (s)he will do so within ten working days of the inquest outcome. (S)he will also send copies of their letter to all interested persons. A copy of any subsequent reply will be sent within five days of its receipt. The Coroner will supply to an interested person, on application, a copy of the inquest verdict or any of the statements or documents produced in evidence within ten working days of the receipt of the prescribed fee (which will vary according to the number and size of documents to be copied). An estimate of the fee will be provided in advance if requested. The Coroner will write to the pathologist instructing him/her to follow the instructions regarding retained tissue (if any) given by the family when the Inquest was opened.

Frequently Asked Questions

Why are the police involved?

The police act as Coroner's Officers. Although the officer may be in uniform, in this instance he/she will not be acting as a police officer (it is not always possible for an officer to be in plain clothes). A visit by the police should not make people think there is anything suspicious about the death. The purpose of the visit is to obtain the information that the Coroner needs to conduct their enquiries and to provide the correct personal information to the Registrar. You will be given a telephone number for the officer and will be able to ask them any questions you might have regarding a post-mortem or inquest.

What are the duties of a Coroner’s Officer?

  • To liaise with the family regarding the procedures involved in the conduct of the Coroner's inquiry.
  • To contact the Coroner on your behalf if you so wish and to guide you through the time leading up to an Inquest if one is necessary.

What happens if someone dies in Scotland or abroad?

When the body of the deceased arrives within the County, the Coroner's jurisdiction arises and the death is then treated in exactly the same way as if the death had occurred here, rather than abroad. The only difference is that the Death Certificate will be issued in the country where the death occurred rather than by the Registrar here.

What happens if I wish to move the body of the deceased out of England and Wales?

The Coroner must give permission (an "Out of England Order") for a body to be moved out of England or Wales. This permission has to be obtained at least four days before the body is to be moved (although the Coroner may be able to give permission sooner) so that any necessary enquiries may be carried out. The Funeral Director will make all the necessary arrangements. Permission must be obtained whenever the funeral is to take place outside England or Wales. This procedure applies in all cases where the body is to be moved out of England or Wales, not just where a death was reported to the Coroner.

What if the deceased dies unexpectedly in hospital?

If the death occurs in hospital and the cause of death is unknown, the Coroner will arrange for the postmortem examination to be carried out by a pathologist other than one employed at or connected with that hospital, if a relative asks the Coroner to do so and if it does not cause an undue delay.

Why is the Coroner Involved?

The Coroner has a duty to investigate and record the details of any sudden death where the cause is not known, violent or unnatural deaths and any deaths whilst the deceased was in lawful custody. A death may be reported for a number of reasons. It does not mean that there is anything suspicious about the death, it may be that the Doctor is unsure of the exact cause or that the person has died earlier than expected, suffered from an industrial disease, died during a surgical operation, or before recovery from an anaesthetic. When a death is reported to the Coroner (s)he may:

  • be satisfied by the doctor as to the cause of death and proceed no further
  • decide to carry out a post-mortem, and on the results of that examination decide not to hold an inquest
  • hold an inquest after a post-mortem examination
  • hold an inquest without a post-mortem if the deceased was known to have died from a previously diagnosed industrial disease e.g. Mesothelioma

What is a post-mortem?

This is an examination to determine the medical cause of death. In some cases organs or tissue samples may be retained for further investigation. The post-mortem will be carried out by a consultant pathologist (when a young child dies a paediatric pathologist will carry out the examination).

What is a post-mortem?

This is an examination to determine the medical cause of death. In some cases organs or tissue samples may be retained for further investigation. The post-mortem will be carried out by a consultant pathologist (when a young child dies a paediatric pathologist will carry out the examination).

Why have a post-mortem?

If the deceased's own GP or the hospital doctor cannot give a medical cause of death then an examination must take place to determine the cause.

Can I object to a post-mortem?

No. The Coroner has a legal duty to ascertain the cause of death, and if the doctor cannot satisfy the Coroner of this a post-mortem examination must take place.

Who organises and pays for the transport of the deceased to and from the post-mortem?

The Coroner's officer will organise the removal of the deceased to and from the hospital. The Coroner's office will pay for this service. You are not obliged to retain the services of the Funeral Director appointed by the Coroner to transport the body of the deceased to and from the hospital. You may appoint a Funeral Director of your choice to organise the funeral.

What happens if the child wished to be an organ donor?

Donation of organs is regulated by the Human Tissue Authority. Further information on frequently asked questions related to this topic can be found on the FAQ – Coroner page of the Human Tissue Authority website (www.hta.org.uk). You and the Coroner will liaise with the doctor or hospital so that the necessary arrangements can be made as soon as possible. The desire to donate organs must not however impede the Coroner's duty to ascertain the cause of death.

Why organs are sometimes removed from the body of the child and what happens to these?

Sometimes the pathologist needs to carry out a more detailed investigation of particular organs in order to establish the cause of death. If he /she does this then the pathologist must tell the Coroner for how long the organs should be retained. The Coroner will notify the family of this and ask them to tell him what they wish to happen to the organs at the end of that period. Usually, the pathologist only needs to take a very small sample of an organ, rather than removing the organ itself. This sample then forms part of the child's medical records.

Do I have to accept the result of a post-mortem?

No. You can ask the Coroner for a second post-mortem but this will be at your cost and you will need to make all the arrangements yourself.

Will a post-mortem delay the funeral?

Not usually. The Coroner and pathologist understand the desire on the part of the family to deal with matters expeditiously, particularly in cases where the religious or cultural beliefs of the family require a funeral to be held within a particular time period. However there are some cases where a slight delay occurs. In such cases an explanation will be given to the family together with an estimate of how long the delay will be. In cases where an organ is removed for further examination the body of the child can be released to the family immediately so that the funeral can be held without further delay. However, if there is a wish for the organ to be re-united with the body before the funeral then there will be a delay in releasing the body. You will be advised how long this is likely to be.

Can I have a copy of the post-mortem report?

The Coroner will usually supply a copy of the report to "properly interested" persons (immediate family, legal representatives of involved in the inquest) on application. The Coroner's Officer will usually explain the main points of the report to the family as soon as it is available. Your G.P. will be able to answer questions in more detail.

Who are ‘Properly Interested Persons’?

They are the people who have a right to participate in the Inquest, by receiving copy statements and asking questions at the hearing and are known as Properly Interested Persons. The Coroners Rules 2013 sets out a list of who falls within this definition.

When can I get a death certificate /Interim Death Certificate?

When the Coroner is given a cause of death by the doctor, the doctor and the Coroner will notify the Registrar of the death. This will happen normally within 24hrs. You may then ring the Registrar to make an appointment to visit the Registrar and register the death. You must do this in person. If the Coroner has decided to hold a post-mortem when (s)he receives the report, does not require an inquest to be held, (s)he will send a certificate to the Registrar to register the death. (This happens usually within 24hrs of the report being received by the Coroner). The Coroner's Officer will have told you the main points of the report and will tell you where when and how you may obtain a certificate. If the Coroner has decided to hold an inquest then a full death certificate will not be available until after the inquest is concluded. However to enable the family to deal with banks, insurance companies, pension provider, National Savings, or any other body which needs official confirmation of the death the coroner will, on request, issue an "Interim Certificate as to the Fact Of Death", more commonly known as an "INTERIM DEATH CERTIFICATE". The interim certificate is not a death certificate. Copies of this are supplied to the next of kin once the Inquest has been opened. Do not send all copies away – keep one copy in case you need to have certified copies made for other institutions. Certified copies can be obtained from a solicitor.

Where do I get a death certificate?

Death certificates are issued by the local Registrar of Births, Deaths and Marriages.

Why hold an inquest?

The Coroner is required to establish who died, how, when and where. "How" is defined as both the medical cause of death and the way in which the death came about. The Coroner must also reach a conclusion about such deaths, (e.g. accident, misadventure, suicide etc.) The Coroner is NOT concerned with matters of fault or blame. Where needed, an inquest will be opened to take evidence of identity and brief circumstances before being adjourned to allow a full investigation to be conducted. The inquest is then resumed when the Coroner will consider (in public) all the evidence before making the findings that the law demands.

When will the Inquest be held?

Where reasonably practicable the inquest will be held within 6 months of the date of death. There are some cases that take a considerable amount of time to enquire into and it may not be possible to hold the final hearing within 6 months. However, if this is the case you will be notified of this, given reasons for it and the case will be regularly reviewed by the Coroner to avoid unnecessary delays. If there is a criminal prosecution in relation to the death then (depending upon the charges brought) the inquest will be adjourned until the outcome of those proceedings is known. Depending upon the nature of those proceedings (e.g. a murder trial) the Coroner may decide that it is not necessary for the inquest to be resumed because all the information that the Coroner needs has been disclosed in the course of that trial. The Coroner, in such a case, will then register the death as if an inquest had been held. Information regarding the inquest can be obtained from this site.

Do I have to go to the inquest?

You are only obliged to attend an inquest if you have received a witness summons to attend. It is an offence to disregard the summons.

What happens in an inquest?

The Coroner will explain how the inquest is to be conducted. (S)He will then determine who is present and if there is any legal representation. Evidence is then given either:

  • on oath by witnesses in person
  • by statements being read into evidence by the Coroner
  • from reports, plans or other documents with which the Coroner has been provided
  • the Coroner will then consider all the evidence and reach her conclusions
  • the Coroner will record the details required by the Registration Act which will allow her to register the death on behalf of the family

Can members of the family speak at the Inquest?

Yes. The Coroner will give you the opportunity to comment either formally, by giving sworn evidence, or informally. (S)he will ask you if you have any questions for individual witnesses or about the content of any statement or document which is read out. You will be given the opportunity to add anything you feel might be relevant to the Coroner's understanding of the situation. The Coroner will then assess the evidence and announce publicly, their findings. You may be asked to confirm certain personal details of the deceased as required by the Registration Acts to enable the Coroner to register the death.

Why do some inquests have a jury?

The Coroners and Justice Act 2009 requires a jury in certain types of case. The majority of inquests are conducted by the Coroner alone. Although the procedure with a jury Inquest is rather different the function and purpose of the inquest remains the same.

Will I/the family need a solicitor?

It is not usually necessary to be legally represented at an inquest because an inquest is an inquiry conducted by the Coroner and not a trial. You may wish to be legally represented at the inquest. You can take advice from any firm of solicitors or Advice Centre as to the best way of dealing with this. The Coroner cannot advise you on which solicitor you should consult.

What does it mean if I am called as a witness?

Witnesses are called to the inquest to tell the Coroner what they know or what they saw or did in connection with the death that the Coroner is investigating. This may be because you witnessed the incident in which the deceased died or because you have information that explains why certain things were done which shed light on the circumstances surrounding the death. It is not usually necessary to be legally represented at an inquest because an inquest is an inquiry conducted by the Coroner and not a trial. You may wish to be legally represented at the inquest. You can take advice from any firm of solicitors or Advice Centre as to the best way of dealing with this. The Coroner cannot advise you on which solicitor you should consult. Witnesses give evidence on oath, either by swearing on a Holy Book to tell the truth or by making a solemn declaration (called an Affirmation) that the evidence to be given is the truth. If, having sworn to tell the truth, false evidence is given, then the criminal offence of perjury is committed. The Coroner and the Courts always view this seriously. A witness who commits perjury will be reported to the police with a view to prosecution. If you require a Holy Book other than the Christian Bible on which to swear the oath please inform the Coroners Office in advance of the Inquest. The Coroner questions the witness so that the evidence, which the witness can give, is fully explored. After the Coroner's questions the family or other properly interested persons may, with the consent of the Coroner, ask questions.

Do I/the family have to accept the conclusion of the Inquest?

It is sometimes possible to challenge the verdict of the inquest by way of an application to the High Court for a judicial review. You should take legal advice about such a course of action as soon as possible after the Coroner has made a decision.

Will the press be present?

The press have the right to be present. An inquest MUST be held in public. The media are not entitled to any more information than that which is given in court.