Coroners are independent judicial officers, appointed by local authorities. Deaths are reported to the coroner if they’re violent or unnatural (including a workplace fatality, for example), sudden or unexplained, occurred in custody or state detention or are due to industrial disease or medical negligence.
A coroner’s statutory duty is to determine:
- Who the deceased was.
- When and where they died.
- How they died.
- The circumstances surrounding the death.
The process begins with information-gathering, narrowing down key issues and setting the inquest’s scope. Coroners have discretionary powers to compel evidence, including the delivery of documents, the preparation of witness statements and summoning witnesses to court. In certain cases, they may impose criminal sanctions, including fines or imprisonment if evidence isn’t provided in-line with a coroner’s directions.
Once all relevant information has been gathered, the coroner decides who must give oral evidence in court. If evidence is uncontroversial, it may simply be read into the court record — so a clear, detailed statement can sometimes prevent the need to appear in person. If called to give evidence, witnesses testify under oath, reinforcing their duty to the court. The coroner and Properly Interested Persons (PIPs) — including the deceased’s family — may ask questions. Formalities are important. Witnesses must address the coroner as ‘Sir’ or ‘Ma’am’. Increasingly, courts allow witnesses to attend remotely. However, it’s crucial to treat any remote location as an extension of the courtroom.
A core function of the coroner’s court is to identify risks and prevent future deaths. If an investigation highlights ongoing concerns, the coroner issues a Prevention of Future Deaths (PFD) report. While the coroner may suggest that action should be taken, they can’t specify what that action must be.