Coroners, post-mortems and inquests

Coroners are independent judicial officers who are available to deal with matters relating to deaths that may require further investigation to establish the cause of death.

What do coroners do?

In Northern Ireland, coroners can either be barristers or solicitors and are appointed by the Lord Chancellor. Coroners inquire into deaths reported to them that appear to be:

unexpected or unexplained
as a result of violence
an accident
as a result of negligence
from any cause other than natural illness or disease
in circumstances that require investigation

A coroner will seek to establish the cause of death and will make whatever inquiries are necessary to do this, for example - ordering a postmortem examination, obtaining witness statements and medical records, or holding an inquest.

When is a death reported to a coroner?

A death is reported to a coroner in the following situations:

a doctor did not treat the person during their last illness
a doctor did not see or treat the person for the condition from which they died within 28 days of death
the cause of death was sudden, violent or unnatural such as an accident, or suicide
the cause of death was murder
the cause of death was an industrial disease of the lungs such as asbestosis
the death occurred in other circumstances that may require investigation

A death in hospital should be reported if:

there is a question of negligence or misadventure about the treatment of the person who died
they died before a provisional diagnosis was made and the general practitioner is not willing to certify the cause
the patient died as the result of the administration of an anesthetic

A death should be reported to a coroner by the police, when:

a dead body is found
death is unexpected or unexplained
a death occurs in suspicious circumstances

A death should be reported by the governor of a prison, immediately following the death of a prisoner.

What happens once a death is reported to a coroner

Initially a coroner will gather information to investigate whether a death was due to natural causes and if a doctor can certify the medical cause of death.

If the reason why a doctor cannot certify the death is simply because they have not treated the patient in the last 28 days, then the coroner will discuss the cause of death with the doctor. If a coroner is satisfied that death was from natural causes and no further investigation is necessary, then they may accept the medical cause of death that a doctor gives and issue a Coroner's notification to enable the death to be registered.

If a doctor cannot certify the medical cause of death then a coroner will investigate the death and may order a post-mortem examination to be carried out.

Death registration and funeral arrangements

If the death was due to natural causes which a doctor is able to confirm, the Coroner will advise the Registrar by issuing a Coroner's notification and the death can be registered and a death certificate issued relatively quickly.

However, if a post mortem examination is ordered, or an inquest may be held, then the death cannot be registered until the Coroner's investgation has been completed. A coroner can issue a 'Coroner's Certificate of Evidence of Death' to the family on their request and this can sometimes assist in the administration of the estate, although not all financial institutions will act on it. This certificate cannot be used to formally register the death.

A funeral may take place once the Coroner is satisfied that the body is no longer required for the investigation.

Postmortem examinations

A postmortem examination is a medical examination of the body. It is carried out on behalf of a coroner by a pathologist in the State Pathologists Department or, in certain cases, by a hospital pathologist.

If the postmortem examination shows that the death was from natural causes and a coroner decides there is no need for an inquest, then a coroner will issue a certificate so that the death can be registered.

If the postmortem examination shows that the death was not from natural causes, then a coroner may decide to hold an inquest and the death cannot be registered until after the inquest has been held.

The holding of an inquest is at the discretion of a coroner but the views of the family can be made known and will be considered before any decision is made.

Coroners Liaison Officers

Coroners Liaison Officers are not medical personnel, but people who work for a coroner to help bereaved families when a postmortem examination has been ordered. The Coroners Liaison Officer will contact the family and forward written information to the family in relation to the preliminary cause of death and enclose documentation to assist with financial matters etc.

Coroners Service NI website

Inquests

An inquest is an inquiry into the circumstances surrounding a death. The purpose of the inquest is to establish who the deceased person was and how, when and where the death occurred and to provide the required details to the Registrar of Deaths so the death can be registered. An inquest is not a trial – it is not the function of a coroner to determine, or appear to determine, any question of criminal or civil liability or to apportion guilt or attribute blame.

Further information on the Coroners Service can be found on the NI Courts and Tribunals Service website.

Coroners Service for NI website

A date for the Inquest will be arranged in consultation with the family when a coroner’s investigations are complete. Inquests are open to the public and the media.

Coroners decide who should attend to give evidence as witnesses at an inquest. Witnesses will first be questioned by a coroner, and there may be further questions by ‘properly interested people’ or their legal representatives. Person’s with a ‘proper interest’ include:

relatives of the deceased
the executor(s) of the deceased’s will or persons appointed as the deceased’s personal representative
solicitors acting for the next of kin
insurers with a relevant interest
anyone who may, in some way, be responsible for the death
others at some special risk or appearing to a coroner to have a proper interest

The findings of an inquest will record the essential facts concerning the means by which the deceased came by his or her death.

Public funding for representation for proceedings before coroners may be available, in exceptional cases, through an ex-gratia Legal Aid scheme.