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The Coroner

The coroner is usually a lawyer, a doctor or sometimes both and is an independent judicial officer, this means that no-one else can tell them or direct them as to what they should do but they must follow the laws and regulations which apply. Coroners are supported by their officers, who receive the reports of deaths and will make enquiries on behalf of the coroner.

The coroner reviews the deaths that are reported to them. It is their duty to find out the medical cause of the death, if it is not known, and to enquire about the cause of death, if it was due to violence or otherwise unnatural.

When is a death reported to the coroner?

In some instances there is a legal requirement for the doctor to refer a death to the coroner. There are a number of reasons why a death may be referred including:

  • If the cause of death is unknown or unclear
  • If the death occurred while the patient was undergoing a medical or surgical procedure or by lack of treatment
  • The death may have been caused by trauma, violence or physical injury, intentionally or otherwise
  • If the death occurred before waking from an anaesthetic
  • If the death relates to an industrial illness or injury
  • If the death was unnatural or occurred under suspicious circumstances
  • If the doctor treating the deceased had not seen them either after the death or in the 14 days before their death.
  • If the death may have arisen as a result of self-harm or neglect, intentional or otherwise
  • If the death may have been caused by neglect of failure of care by another person
  • If the death arose whilst the deceased was in a state of detention (prison or police custody, mental health sections)
  • If the death was otherwise unnatural

What will the coroner do?

The coroner may be the only person who can certify the cause of death. The doctor will write on the formal notice that the death has been referred to the coroner.

The coroner may decide that the death was quite natural and will allow the doctor to issue the Medical Certificate of Cause of Death. If not, the coroner may ask a pathologist to undertake a post-mortem examination.

The coroner will then take responsibility for issuing the necessary documentation so that the death can be registered. A coroner’s officer will contact the nominated next of kin or appropriate person to advise them regarding the procedures.


The coroner may decide a post-mortem is needed to find out how the person died. Post-mortems, for deaths that occur at Liverpool Heart and Chest Hospital, are undertaken at the Royal Liverpool & Broadgreen University Hospital (RLBUHT).  Arrangements will be made for our contracted funeral directors to transfer the deceased to the mortuary.

You cannot object to a coroner’s post-mortem - but if you have asked, the coroner must tell you (and the deceased’s GP) when and where the examination will take place.

After the post-mortem

The coroner will release the body for a funeral once they have completed the post-mortem examinations and no further examinations are needed.

If the body is released with no inquest, the coroner will send a form (‘Pink Form - form 100B’) to the registrar stating the cause of death.

The coroner will also send a ‘Certificate of Coroner - form Cremation 6’ if the body is to be cremated.

If the coroner decides to hold an inquest

A coroner must hold an inquest if the cause of death is still unknown, or if the person:

  • possibly died a violent or unnatural death
  • died in prison or police custody

You cannot register the death until after the inquest. The coroner is responsible for sending the relevant paperwork to the registrar.

The death cannot be registered until after the inquest, but the coroner can give you an interim death certificate to prove the person is dead. You can use this to let organisations know of the death and apply for probate.

When the inquest is over the coroner will tell the registrar what to put in the register.

For further advice, please contact the Patient and Family Support Team on 0151 600 1038, or 0151 600 1639 or 0151 600 1517.