Guidance

Annex 4: Coroner (England and Wales) - role and responsibilities

Updated 12 February 2026

Applies to England and Wales

1. Background

1.1 

Coroners are independent judges. They have a statutory responsibility (see section 1 of the Coroners and Justice Act 2009) to investigate a death reported to them which they have reason to suspect was violent, unnatural, of unknown cause, or that arose in prison or otherwise in state detention. For a coroner to have jurisdiction, the deceased person’s body must usually be lying within the coroner’s area at the time the report is made. The exception to this is that coroners can seek permission from the Chief Coroner to investigate if they have reason to believe that a death occurred in order near their area but there is no body (for example where the person died in a house fire and their body was not recovered). A coroner’s investigation can lead to a type of court hearing, called an inquest. 

1.2 

In cases involving deaths abroad, if the body is not repatriated, there will be no investigation by a coroner in England and Wales. The repatriation of cremated ashes does not trigger a coroner’s involvement.  

1.3 

The coroner must decide whether they have a duty to investigate the death under section 1 of the Coroners and Justice Act 2009. If a death is reported to a coroner that the coroner suspects was violent or unnatural, and the person’s body is in the coroner’s area when the report is made, the coroner must investigate. This means that families of those who are repatriated after being killed by murder or manslaughter overseas should expect an inquest to take place. 

1.4 

The Ministry of Justice produces a document called a Guide to Coroner Services for Bereaved People which aims to explain the process; please refer to Annex 5 (Useful links) for the latest version.  

1.5 

Once a death is reported to a coroner, the coroner has lawful control of the deceased person’s body. As a result of this, the coroner is the only person who can authorise a post-mortem examination. The coroner will retain control of the body until the coroner makes the decision to release the body for burial or cremation.  

1.6 

The coroner service is a local service, funded by local authorities. England and Wales are divided into a number of coroner areas. Those areas vary in size and have different arrangements depending on various local factors including their geographic make-up and the nature of their populations. Each coroner area has a senior coroner who is primarily responsible for the provision of the local coroner service. The senior coroner is typically supported by other coroners who work within the coroner area, including some who work part-time as coroners and part-time within the legal professions. Judicial work, including inquests, can be carried out by any of the coroners in the area.  

1.7 

The coroner service is supported by coroner’s officers and other administrative staff supplied by the local authority and/or local police force. Staffing levels vary from area to area. In some areas the level of support is very limited, as are the resources for administrative and judicial work. 

1.8 

The Chief Coroner, an office created by the Coroners and Justice Act 2009, is the judicial head of the coroner system, providing leadership for coroners in England and Wales.  

1.9 

The coroner’s jurisdiction is territorial, and it is generally the location of a body that determines which coroner may have jurisdiction in a particular case. It is possible for cases to be transferred between coroner areas, either through agreement between coroner areas, or as a result of a direction by the Chief Coroner.  However, the area where the body is to be buried/cremated will normally take jurisdiction when a body is repatriated.  

2. The inquest 

2.1 

The purpose of the inquest is to provide answers to four factual questions: who the deceased person was; and how, when and where they came by their death. In most inquests the ‘how’ component is taken as meaning “by what means” the deceased person came to die, a question directed to the immediate means of death. At the end of an inquest, the coroner or jury make determinations which answers the four statutory questions.  

2.2 

The inquest is not a trial of rights and obligations, but a fact-finding exercise, with no parties or pleadings. The participants are known as ‘interested persons’. The inquest findings cannot appear to determine civil liability. Findings appearing to determine criminal liability are permitted, but not on the part of a named person.  

2.3 

The coroner must ensure that the relevant facts are fully and fairly investigated and are the subject of public scrutiny during the inquest hearing. The coroner alone is responsible for deciding on the scope of the inquest and the evidence to be called. The relevant issues will vary from case to case and may or may not be the subject of disputed evidence. This means that the nature of an inquest (what evidence is heard and what the inquest looks at) can vary from case to case.  

2.4 

There is no provision for the coroner to hold any form of inquiry overseas or to summon witnesses from another country.  

2.5 

The coroner will, as a matter of statutory obligation, inquire into deaths that are violent or unnatural, or where the cause of death is unknown even if the Death Certificate from foreign authorities records that the death was attributed to natural causes. The fact that the medical cause of death is stated to be a natural cause by foreign authorities does not necessarily mean that the death was not unnatural from the point of view of the law in England and Wales. The coroner may require a post-mortem examination, even if one was conducted abroad.  

3. Requests for information when a death has occurred abroad  

3.1 

All requests by coroners for information from foreign authorities are routed through the FCDO Consular Directorate’s Coroner Liaison Officer (CLO). The CLO will be asked to forward the request to the relevant consular post overseas who themselves will request the information of the foreign authority. The report, when provided, will then be returned to the coroner through the same channels. The coroner will usually liaise with the CLO (and police Family Liaison Officer, where appointed) regularly in advance of the inquest, to obtain all relevant information that may be of assistance. The types of information that may be requested by the coroner include:  

• death certificate

• post-mortem examination report (including photographs, if taken)

• toxicology reports (if samples taken)

• medical reports

• photographs, plans or drawings of the scene

• witness statements

• police reports

3.2 

It is important to note that the information requested is subject to determination by the coroner. The evidence considered by the coroner will vary depending on the facts of each particular case.  

3.3 

The translation of documents into English may be required to ensure that bereaved families, as interested persons, are able to participate fully in the inquest process. However, whether particular documents should be translated and how that should be done is a matter for the coroner to determine. For example, a coroner may decide that a summary or brief description of one document, or of a series of documents, is sufficient to enable proper participation.  

3.4 

Disclosure of documents (translated or otherwise) by the coroner should be done so in advance of the inquest to enable proper participation by the bereaved family (and other interested persons).  

4. Working with the police  

4.1 

Coroners routinely rely on other investigative bodies and agencies to provide evidence and information which can form part of the coroner investigation. In overseas cases, the coroner may ask the foreign authority to provide information around the death, however the response to this will vary considerably. Requests may take a long time to arrive or may never arrive. If the police in England Wales are involved, they can assist the coroner by providing information in the course of their own investigation. The coroner has no power to direct a police investigation, but may request that the police assist with coronial inquires.