Role of the Coroner

A coroner is an independent judicial office holder acting on behalf of the Crown to investigate the cause and circumstances of violent or unnatural deaths, or sudden deaths of unknown cause.

A duty arises to investigate a death if the Coroner has reason to suspect:

a. The deceased has died a violent or unnatural death,

b. The cause of the death is unknown, or

c. The deceased died whilst in custody or state detention.

For the purposes of these Inquests a death is deemed to be unnatural if:

1. The death was at least contributed to by neglect or
2. An unexpected death from natural causes, results from culpable human failure.

Preliminary Inquiries

The coroner is permitted to make preliminary inquiries to see whether the duty to investigate and hold an Inquest is engaged and may make whatever inquiries seem necessary. This is the procedure which has been adopted for the purpose of those Inquests.

Purpose of the Inquest

The matters to be ascertained at an inquest are:

1. Who the deceased was;
2. The place of his or her death;
3. The date and time of the death; and
4. How he or she came by their death.

In the case of these Inquests as Article 2 of the European Convention on Human Rights has been engaged “how” will be interpreted as by what means and in what circumstances in accordance with section 5(2) of the Coroners and Justice Act 2009. This means that systemic failings will form part of the investigations. An inquest is a fact finding inquiry conducted by a coroner. It is not permitted to reach any conclusion that appears to determine civil or criminal liability however it can record factual failures that are found on the evidence to have caused or contributed to the death. There is, however, an obligation on the Coroner to report any evidence of criminal liability for a homicide offence to the prosecution authorities.