The Coroner's Office and inquests

The Coroner's role

The Coroner has a duty to investigate those deaths that are reported to the Coroner. This can be as a result of a referral from a hospital, GP or in the case of a death in the community, the police. The Coroner’s enquiries are made for the Coroner by the Coroner’s officers and are carried out as sensitively as possible, but the Coroner must still ensure that proper enquiries are made.

The Coroner is an independent judicial officer appointed to investigate all sudden, violent and unexplained deaths of persons who have either died in, or whose bodies are brought into, the area. In certain cases the Coroner must hold an inquest to determine who, when, how and in what circumstances a person has died.

The area covered by H M Coroner for the Western Area of West Yorkshire includes the metropolitan districts of Bradford, Kirklees and Calderdale with a population of 1.3M. The Coroner's Office deals with approximately 3,200 reported deaths and approximately 500 inquests per year. In some cases the Coroner will issue a form enabling a death to be registered as natural through a medical certificate issued by a doctor who has attended the deceased. In other cases the Coroner will direct a post-mortem examination (also known as an autopsy) to be performed by a pathologist, and following the result of this will send a form to the registrar in order for a death then to be registered if the examination shows it was of natural causes.

There are also cases where a Coroner will decide to hold an inquest. An inquest is a court hearing where the Coroner hears evidence to decide who is the person who has died, and how, when and where s/he came by his/her death.

Post-mortem examinations

Sometimes a post-mortem examination (also called an autopsy) will be considered necessary to establish the medical cause of death. The decision is for the Coroner to make. A report is delivered to the Coroner by the pathologist within a few weeks of the post-mortem examination to confirm or reveal the medical cause of death. However, sometimes additional tests or other sample investigations are necessary; this may take considerably longer to return a result. Normally the Coroner instructs the pathologist about the retention and the return to the body, or disposal in a proper manner, of any tissue samples that were taken at the post mortem examination. Samples are usually very limited in quantity.

The body of the person who has died is usually released for burial or cremation soon after the post-mortem examination is undertaken, but there may be a delay if further tests or examinations are necessary. In homicide cases, a second examination may need to be performed. The Coroner is very much aware of the need of the family for return of the body for a proper funeral and burial or cremation to take place, and avoids delay whenever possible. A non-invasive procedure (in the form of CT scanning) may be an alternative to an invasive post-mortem examination; this is a decision for the Coroner on advice from the pathologist on its suitability in a particular case as a way of ascertaining the cause of death and only if a scanner is available for this purpose.

When the post-mortem report is received the Coroner will consider it and may decide that the Coroner is able to conclude the Inquest as a Documentary Inquest under Rule 23 of the Coroner's (Inquests) Rules 2013. This means that witnesses will not be required to attend to give evidence in person. The Inquest will not be concluded in this way without consultation with the family and other interested persons.

Consultation and information is via the Coroner’s Officer who looks after the case.

Organ donation

If a death has been reported to the Coroner, and the family wish to consider organ donation, or the person who has died requested this, you will need immediate advice. This can be sought from the hospital or doctor, or from the Coroner's officer. The Coroner must be told and must agree before organs can be removed in the case of a death reported to the coroner. In some cases, organ donation may unfortunately not be possible for medical or legal reasons, or because of the delays which necessarily occur when a death has to be investigated.

Removing a body abroad - applications for permission

A body under the Coroner’s jurisdiction may not be removed out of England without the Coroner’s consent. The Coroner will make every effort to complete his enquiries and decide such application promptly after receiving notice, including weekends and bank holidays. Applications for such 'Out of England' permissions should be made via the Coroner’s Officer, and this is usually done by the undertaker.

Treasure inquests

Coroners have responsibility for enquiries into treasure finds. The legislation governing treasure (formerly known as 'Treasure Trove') is in the Treasure Act 1996.

In England, Wales and Northern Ireland, all finders of gold and silver objects, and groups of coins from the same finds, over 300 years old, have a legal obligation to report such items. Prehistoric base-metal assemblages found after 1st January 2003 also qualify as treasure.

All treasure governed by the Act when discovered is subject to an inquest at a Coroner's court to establish the circumstances of its loss or deposition.

The definition of treasure is complicated, and if you find something that you think may be treasure you should contact your local museum in the first instance.

The best source of information about treasure (which includes a comprehensive Code of Practice) and the Portable Antiquities Scheme can be found at:

The Coroner's Service Charter

All the work of the Coroner's Service is covered by the Coroner's Service Charter.

This Charter, which covers the Coroner's Service for the Western Area of West Yorkshire, tells you what standards of performance you can expect from the Coroner's Service and what to do if something goes wrong. The commitments of the Coroner, officers and administrative staff include these:

  • to treat all bereaved relatives and other members of the public courteously and sympathetically at all times, and to give respect to matters of religious faith and cultural traditions within the constraints of the Coroner’s statutory duties; 
  • to be as impartial as possible in finding out the facts surrounding a death to comply with the Coroner's statutory responsibilities; and 
  • to keep sensitive information as confidential as possible within a system based on public court hearings and give explanations for the procedures adopted in particular cases where the Coroner is satisfied that the person has a proper interest.

Concerns and complaints

If you have a cause for concern about a death then you are entitled to raise these concerns with the Coroner.

Please contact the Coroner's Office to report those concerns to the Coroner.

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