Coroner's Inquest

Judiciary guidance explains that coroners are independent judicial office holders (like judges) who investigate certain deaths, and that a coroner has a duty to investigate any death which is violent or unnatural or the cause of which is unknown or which occurs in prison, police custody or other state detention. The Chief Coroner, who heads the coroner service of England and Wales, has responsibility to make formal orders under the Coroners and Justice Act 2009 and sits in the High Court on inquest appeals.

Where an investigation is required, the guidance describes an inquest as a public court hearing (in the coroner's court) in which the coroner — or a jury in the small minority of cases where one sits — establishes the answers to the questions of who died and when, where and how they came by their death. Permitted conclusions include amongst others natural causes, accident, road traffic collision or suicide, and the coroner's findings are recorded on the Record of Inquest. Not every death reported to a coroner leads to an inquest: where the medical cause of death is established as natural, for example after a post-mortem, no further investigation may be needed.