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14 June 2014
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What kind of deaths do get reported to the Coroner in England/Wales?


Firstly, it's important to note that not every death gets reported to the Coroner.  If someone dies from obvious natural causes and the treating doctor is in a position to issue the 'Medical Certificate of the Cause of Death', than the Coroner does not need to be involved. 

Let's start with the obvious deaths which would need to get reported to the Coroner.


  1. Suspicious death

- shooting
- stabbing
- strangulation / smothering
- if the death occurred from injuries sustained in a fight
- if the death occurred after a any assault, i.e. robbery victim got pushed over, hits his head and now dies
- if police feel the circumstances are not clear i.e. someone gets found deceased in a property and the property was unlocked, items disturbed, lots of blood etc
- anything really which the police deem suspicious

Importantly, in the first instance, it is the police who decides that the death could be suspicious and not the Coroner. I always tell bereaved families 'if it was suspicious, than you would not talking to me now, but to a Detective.'

Of course, if the Coroner's Office finds anything untoward in the course of our investigation which initially was deemed as 'non-suspicious' we can than inform the police. But this is rare and mostly happens when subsequently new information comes to light. 


     2. It is believed that the cause of death would be clearly unnatural (=   not naturally occurring disease) 

- road traffic collision
- found in water (river / lake  or bath water)
- electrocution
- suspension (hanging)
- drugs involved (either known drug user, or drugs / drug paraphernalia  found nearby)
- possible medication overdose (either deliberate or accidental)
- auto-erotic
- trips / falls (down stairs etc) 

This is not an exclusive list.
Please also note that the words 'accident' or 'suicide' are not causes of death, but a Coroner's verdict (I will write about Coroner's verdicts at a later stage on in this series). To illustrate - a hanging can be suicide or accidental. 



      3. The medical cause of death is unknown and/or the death was unexpected


This mostly is to do with the fact that in England and Wales, it is not sufficient to simply put 'natural causes' on the Medical Certificate of the Case of Death (MCCD -an MCCD allows you to register the death, obtain a death certificate and bury/cremate the body.) The Doctor who issues such certificate must be reasonably sure of the medical cause of death (to the best of his/her knowledge and belief). In order for a Doctor to issue a MCCD, they would need to fulfil certain conditions:


  • they need to have seen the patient in his lifetime
  • they need to have treated the patient in the last 14 days
  • they need to know the medical cause of death to the best of their knowledge and belief
If the doctor does not meet those conditions, he/she needs to report the death to the Coroner. This doesn't always mean that a post mortem needs to be done. We can authorise the doctor to issue an MCCD if the Coroner is satisfied that no further investigation is needed. Examples of those are: the doctor has not seen the patient within 2 weeks, but the death was clearly expected and the cause of death known (i.e. cancer patient) or the doctor who usually sees the patient is on holiday, but his colleague confirms the death was expected and the cause of death is known.  

- decomposed body (too decomposed to ascertain a medical cause of death)


    4. The death is believed to be related to medical treatment

- death occurred during or shortly after an operation
- possible errors with medication
- death could be related to procedures or treatment i.e. radiotherapy




    5. Work-related death

- if death occurred whilst being at work and is thought to be directly related to the work i.e. roofer falls from ladder
- industrial disease (asbestosis)



    6. Death in Prison, Police Custody or whilst being detained in a Mental    Health Unit

These will always need to be investigated, even if thought to be natural causes i.e. prisoner died from cancer. 
The reason for this is that whilst detained, the deceased is not at liberty i.e. relies on other to a certain extent to get medical treatment, health conditions etc.



    7. Others not covered by above

- neglect (either self-neglect or by others)
- if the death occurred in hospital less than 24 hrs of arriving 
- body which will be taken out of England/Wales
- body which comes into the country 


(not exclusive list, I may add to it as I come across others) 



Which Coroner's jurisdiction (Coroner's area) will be dealing with a particular case? 

The jurisdiction of which Coroner's district investigates is determined by 'where the body is currently lying' . In most cases, this will be the place of death i.e. a person's home address, the hospital, street location.

There are no shared databases, so my Coroner's Office would not know anything about a death which occurred in another area nor would we have access to any information.

Jurisdiction of a case can be transferred to another Coroner. This happens mostly when the body is lying in one jurisdiction, but the incident occurred in another. One example: a person is involved in a road traffic collision in Area 1, but gets flown to a Specialist Hospital in Area 2. The death would be reported to the Coroner in Area 2 but they may approach the Coroner for Area 1 to see if they take this case back. As you can imagine, some jurisdictions (areas) have big trauma hospitals and thus would pick up all the trauma deaths. Not only an issue of work distribution, but if the accident occurred in another area, we can assume that the investigation will take place in the different area and the family may live in that area. So it's also practicalities.