What happens when the coroner is involved

About three in ten deaths in England and Wales are reported to the coroner, and nearly all of them are ordinary deaths that a doctor simply could not certify: the person had not seen a doctor recently, or died suddenly, or the cause was not obvious. A referral is not a suspicion. It is the coroner’s job to establish who died, and when, where and how, and for most families it means a short delay and a certificate from a different office. This guide is the process from the referral to the release, and then the inquest, for the families who have one.

Why a death is referred

A death is reported to the coroner when no doctor can give a cause, when the cause is unknown or the death was sudden, when it was violent or unnatural, an accident, a fall, a suicide, when it happened in prison or police custody, or during or soon after an operation, or when the medical examiner or the family has raised a concern. The referral is made by the doctor, the hospital, the police or the medical examiner, and the family is told. In Scotland the equivalent role belongs to the procurator fiscal; in Northern Ireland to the coroner, under its own rules.

What the coroner does first

The coroner’s officer contacts the family, usually within a day or two, to explain what is happening and to ask about the person’s medical history. If a doctor can, after all, give a cause of death that the coroner accepts, the coroner ends the investigation and the death is registered in the ordinary way. If not, the coroner orders a post-mortem.

The post-mortem

A post-mortem is an examination by a pathologist to find the cause of death. The family cannot refuse it when the coroner has ordered it, but they can ask for a non-invasive one, by scan, where the coroner’s area offers it and the coroner agrees, and some faiths ask for that. It is usually done within a few days. Your loved one is cared for at the hospital or the coroner’s mortuary meanwhile, and the funeral director cannot collect them until the coroner releases them.

The release, and the funeral

Once the post-mortem has given a cause of death, one of two things happens. If the cause is natural, the coroner issues a form to the registrar and the death is registered as usual, with the coroner’s certificate for burial or cremation in place of the registrar’s green form; the funeral goes ahead. If the cause is not natural, or is still unclear, the coroner opens an inquest, and releases your loved one anyway, with an interim certificate of the fact of death for the family’s use with banks and insurers and the certificate the funeral needs. In either case the funeral can happen within days of the release. For a cremation, the coroner’s certificate is what we obtain; direct cremation step by step shows where it sits.

The inquest

An inquest is a public hearing, in a coroner’s court, to establish who died and when, where and how. It is not a trial; no one is on trial and it does not decide blame. The coroner opens it soon after the death and then adjourns it, often for months, while evidence is gathered, and the full hearing takes place when it is ready; the coroner aims to hold it within six months of the death being reported, the average in 2024 was just over seven months, and complex cases are longer. The family can attend, can ask questions of the witnesses, and can be represented, though legal aid for inquests is rare and most families are not. At the end the coroner records a conclusion: natural causes, accident, suicide, an open conclusion, or a short narrative. The death certificate is issued after the conclusion, with the cause the inquest found.

How long each stage takes

The referral to the post-mortem, days. The post-mortem to the release, a few more days, usually inside a fortnight in all. The release to the funeral, whatever the family chooses. The inquest, months, and it does not hold anything else up except the final death certificate.

If you have concerns about the death

Tell the coroner’s officer, in writing if you can. The coroner can widen the investigation, order further tests and call witnesses, and a family’s concern is a proper reason to. The Coroners’ Courts Support Service helps any family through an inquest, free, and the charity INQUEST does the same where the death involved the state, in custody or in detention; the coroner’s office will give you their details.

If the death was abroad, or the funeral is

A death abroad brought home for a funeral here may be reported to the coroner on arrival if it was violent or unnatural, and the coroner may hold an inquest; bringing someone home to the UK explains that. A death here where the funeral is abroad needs the coroner’s acknowledgement before your loved one can leave the country, which is a separate, routine notice with a four-day clock, and sending someone home from the UK explains the difference.

The coroner changes the order of the first three steps in what to do when someone dies, and that page marks where.