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Coroners

Updated: 02 February 2021|Legal Guidance

Introduction

This legal guidance provides prosecutors with information about Coroners and their responsibilities. It also provides operational advice regarding the Agreement between The Crown Prosecution Service, The National Police Chiefs' Council, The Chief Coroner and The Coroners' Society of England and Wales. This guidance should be read in conjunction with the Agreement and supporting tools.

What is a Coroner?

Coroners are independent judicial officers, appointed by the local authority, and are either doctors or lawyers responsible for investigating the cause of deaths. There are around 98 Coroners in England and Wales covering approximately 109 coroner areas (Coroners and Justice Act 2009 [Coroner Areas and Assistant Coroners] Transitional Order 2013), which loosely mirror the boundaries established by local authority districts. Coroners employ officers to assist them with their investigations.

The Coroners and Justice Act 2009 Commencement No. 14 Order 2013 commences the provisions of section 43 [Coroners (Investigations) Regulations 2013] and section 45 [Coroners (Inquests) Rules 2013] of the Coroners and Justice Act 2009. All new appointments of Coroners (of whichever rank) will be of lawyers only.

Since the enactment of the Criminal Law Act 1977, Coroners are no longer able to consider criminal liability as part of their investigations. There is no power available for the Coroner to frame their determination in such a way as to appear to determine criminal liability on the part of a named individual or organisation or civil liability (as defined by section 10(2) of the Coroners and Justice Act 2009).

Office of the Chief Coroner

The Office of the Chief Coroner was created by the Coroners and Justice Act 2009, with the first Chief Coroner being appointed in September 2012. The Chief Coroner heads the coroner system and has overall responsibility and national leadership for Coroners in England and Wales.

The Chief Coroner has the power to 'take over an investigation at any stage' where an individual Coroner's investigation has not been completed within a year from the day in which the Coroner is made aware of the deceased's death (paragraph 26(1) Coroners (Investigations) Regulations 2013). Intervention is not expected in every case, but prosecutors may be contacted by the Chief Coroner, or the Coroner handling the case, for a progress report where the cause of delay appears to lie with the CPS. There is no statutory requirement for the CPS to act, but prosecutors should consider assisting the Coroner to progress the case (where appropriate).

What does a Coroner do?

Coroners inquire into the causes and circumstance of a death under section 5 of the Coroners and Justice Act 2009; inquiries are directed solely to ascertain:

  • who the deceased was;
  • how, when and where the deceased came by his or her death; and,
  • the particulars (if any) required by the Births Deaths and Registrations Act 1953 to be registered concerning the death.

A Coroner will conduct an investigation (legal inquiry) when informed that the body of a person (the 'deceased') is lying within their district (geographical 'jurisdiction'). However, following the commencement of the Coroners (Investigations) Regulations 2013 the Coroner will no longer be restricted to holding inquests within their own districts and will have the option to relocate if it is in the interests of the bereaved family.

The Coroner is expected to open an inquest where there is reasonable suspicion that the deceased has died a violent or unnatural death, where the cause of death is unknown or if the deceased died while in custody or state detention as defined by section 1(2) of the Coroners and Justice Act 2009.

In addition, the Coroner will also investigate where the deceased has not been seen by the doctor issuing the medical certificate, or during the 14 days before the death.

Coroners automatic jurisdiction

Prosecutors should note there is one circumstance where the coroner will have automatic jurisdiction (power to exercise their function): where a death caused by natural causes occurs in a prison or other place of 'custody'. These cases will automatically be referred to the Coroner for an inquest and will be held with a jury present.

The Coroner may also be involved in assisting in the prevention of future deaths by reporting the findings and/ or making recommendations to the relevant authority/ organisation involved in the circumstances of the deceased's death. These recommendations will usually be made by a Coroner under Prevent Future Deaths (PFD) Reports as defined by paragraphs 28 and 29 of the Coroners (Investigations) Regulations 2013.

Are all deaths reported to a Coroner?

The majority of deaths are not reported to the Coroner and, in most cases the deceased's doctor will issue a medical certificate with the cause of death without reference to a coroner, especially if they have been treated for an illness which caused the death.

There is a common duty upon all citizens to give information which will inform a Coroner of circumstances for when an inquest should be held. It is a common law offence to obstruct a Coroner, whether by disposing of a body before a Coroner can openly inquire into the circumstances of a death or acting to prevent an inquest.

What will a Coroner do when a death is reported?

The Coroner will request a post mortem to be carried out by a pathologist to determine the cause of death. An inquest will be held if the cause of death remains unknown after the initial examination, or there is reason to suspect the death was violent or unnatural, or the deceased died in prison.

Where there is a suspicion that a criminal act led to the cause of death, the Coroner will open an inquest and must adjourn it until the outcome of any criminal proceedings is finalised (Para. 1 Schedule 1 CJA 2009). Where criminal charges are being considered for a homicide offence (as defined at Para. 1(6) Schedule 1), further post mortems may take place, which may delay the release of the body to the bereaved family/next of kin (this may be of significance where a body is found and a murder is suspected, but no individual has been arrested on suspicion of the crime). It is for the Coroner to liaise with the bereaved regarding the release of the body, and with the police and CPS where needed if criminal proceedings are being considered.

Will the Coroner arrange a second post mortem?

The majority of cases in which the coroner will be asked for a second post-mortem examination are suspected homicide cases.  Either there is an identified suspect or there is a request from the police to hold a second post-mortem examination where there may be a suspect identified but not yet charged.

The Chief Coroner has issued guidance about post-mortem examinations including second post-mortem examinations.  The guidance sets out some considerations for coroners to assist in deciding whether to arrange a second post-mortem examination.  It identifies that the coroner should carefully scrutinise any request for a second post-mortem and expect to be given reasons for the need for one.  The coroner in granting or refusing a request should give reasons for the decision.

Where the report of the first post-mortem examination is not available before a decision has to be made on a request for a second examination, the coroner should do everything within their power to ensure that a preliminary report or summary conclusions from the first examination are made available at a very early stage.  This approach will allow an informed decision to be taken on whether a second examination is justified.

In cases where the cause of death is not in issue, it is unlikely that a second post-mortem examination will be needed.

The coroner should exercise careful judgment in respect of any request for a second post-mortem examination and should expect proper reasons to be given, pointing as appropriate to the likely issues in the prospective criminal proceedings.

The coroner should disclose a post-mortem examination report to a suspect, (Rule 13(2)(a) of The Coroners (Inquests) Rules 2013).  The coroner may refuse to provide the report where the document relates to contemplated or commenced criminal proceedings (under Rule 15(d)).  Prior to disclosure the coroner is advised to consult with the police and / or CPS.

Road traffic collision deaths

Where there appears to be a genuine prospect of a prosecution for death by careless or dangerous driving then the police may indicate to the coroner that they would like the coroner to authorise a full forensic post-mortem examination (which may amount to a second post-mortem examination if the coroner has already authorised a post-mortem examination).

The Chief Coroner’s guidance identifies that often in road traffic collision deaths, the cause of death is not the issue, rather it is the causal link between the death and the manner and the standard of driving which is the important factor.  In such cases, other than toxicology tests, there should be no need for a forensic or further post-mortem examination.  This may merit further discussion between the CPS and the coroner in individual cases.

Second post-mortem examinations in road traffic collision deaths should in practice very seldom be authorised by a coroner.

Will the Coroner provide the police / CPS with a copy of the second post mortem report?

Where a prosecutor is aware that a second post mortem has been carried out, they should liaise with the police to seek information about the outcome, (it is possible that the second post mortem will be attended by the police and the first pathologist). Where the prosecutor considers that the findings set out in the report about the second post mortem will be of relevance to their decision making and the coroner decides not to disclose the report, the prosecutor should consider asking for a meeting with the coroner. The prosecutor must anticipate that the coroner may be reluctant to disclose the report to the police / CPS due to the content being beneficial to the defence and / or implications at any future trial if police / CPS had sight of the report prior to the individual being charged. The prosecutor should request the coroner to reconsider their decision about non-disclosure of the report.

Prosecutors should note that, on a previous occasion, the CPS has challenged a coroner's decision not to disclose the report of a third post mortem examination. This led to the CPS applying for a witness summons to be issued to require the coroner to surrender the report. At the hearing, it was agreed by the Judge and the CPS that the Coroner was not a compellable witness following the rule in Warren v Warren [1997 QB 488-498], and the witness summons was discharged.

Inquests

What is an inquest?

Inquests are legal inquiries into the cause and circumstances of a death, and are limited, fact-finding inquiries; a Coroner will consider both oral and written evidence during the course of an inquest. The Coroner's duty to hold an inquest is contained in section 6 of the Coroners and Justice Act 2009. Inquests are public hearings and can be held with or without juries - both are considered equally valid. Under Rule 8 of the Coroners (Inquest) Rules 2013, Coroners are required to complete an inquest within 6 months of the date on which the Coroner is made aware of the death, or as soon as is reasonably practicable.

An inquest will open to record a death, ensure the deceased is identified and for a body to be released for burial or cremation. In more complex cases, the Coroner may also hold a pre-inquest hearing(s), where the scope of the inquest will be considered, including possible timeframes and directions to be set. Pre-inquest hearings will usually be held in public except where it is in the 'interests of justice or national security', under Rule 11(5) of the Coroners (Inquests) Rules 2013. The Coroner will invite 'properly interested parties' and/or legal representatives to these hearings for the opportunity to make representations to the coroner, where required. (Categories of individuals identified as 'properly interested parties' can be found in section 47 of the Coroners and Justice Act 2009.)

Inquests will, in most cases, remain adjourned whilst criminal proceedings are being considered. However, where an inquest takes place and a criminal act has not been suspected as leading to the cause of death, the Coroner may restrict any evidence being heard at the inquest if he/she thinks it might prejudice any future criminal proceedings.

It is the Coroner's prerogative to resume an inquest following a criminal trial, but where an inquest does resume, its outcome (conclusion or determination) as to the cause of death, must not be inconsistent with the outcome of the criminal proceedings (as outlined in paragraph 8 of Schedule 1 of the Coroners and Justice Act 2009). It is worth noting that the Coroner is under no obligation to hold an inquest solely in the public interest; an inquest will be held by a Coroner if the circumstances of the death fall under those offences listed in paragraph 1(6) of Schedule 1 of the Coroners and Justice Act 2009.

Inquest conclusions

There is no definitive list of conclusions available to a Coroner. The following are those most commonly used:

  • natural causes (including fatal medical conditions);
  • accident or misadventure;
  • industrial disease;
  • dependence on drugs/non-dependent abuse of drugs;
  • attempted/self-induced abortion;
  • disasters subject to public inquiry;
  • lawful killing (such as deaths caused during acts of war, or self-defence);
  • unlawful killing;
  • suicide;
  • open verdict (where there is insufficient evidence for any other verdict).

The commencement of the provisions in the Coroners and Justice Act 2009 have added some further possible conclusions to this list:

  • alcohol/drug related death, and
  • road traffic collision.

The conclusion of unlawful killing is restricted to the criminal offences of murder, manslaughter (including corporate manslaughter), and infanticide. Cases where driving causes death may, therefore, only be regarded as unlawful killing for inquest purposes if they satisfy the ingredients for manslaughter (gross negligence manslaughter) or where a vehicle is used as a weapon of assault and deliberately driven at a person who dies (murder or manslaughter depending on the intent).

Standard of Proof & Unlawful Killing Conclusions

InMaughan, R (on the application of)v Her Majesty's Senior Coroner for Oxfordshire [2020] UKSC 46 (13 November 2020) the Supreme Court clarified that the standard of proof for suicide and unlawful killing in an inquest is the civil standard of the balance of probabilities and not the criminal standard of beyond reasonable doubt.

The decision of the Supreme Court in Maughan means that the ordinary expectation that a prosecution should follow a verdict of unlawful killing, found in cases such as R v DPP ex parte Manning [2001] QB 330 and R v (on the application of Dennis) v DPP [2006] EWHC 3211, no longer applies. This is because an unlawful killing verdict can now be reached on the balance of probabilities. However, where a decision is taken not to proceed with a prosecution following a verdict of an unlawful killing prosecutors should continue to provide a clear explanation for that decision.

Rule 25 (4) of The Coroners (Inquests) Rules 2013 requires a coroner to adjourn an inquest and notify the Director of Public Prosecutions, if during the course of the inquest, it appears to the coroner that the death of the deceased is likely to have been due to a homicide offence and that a person may be charged in relation to the offence.

  • The coroner will suspend his or her investigation (and adjourn any inquest held as part of that investigation) upon the police notification, pending completion of the police investigation (and, where appropriate, prosecution).
  • The police will, when referring a case to the CPS for early advice or where a charging decision is being requested, provide the details of the coroner to enable the prosecutor to establish early contact.
  • The CPS will notify the coroner where his or her investigation can run in parallel with the criminal proceedings.
  • The coroner will only resume the investigation (and any inquest where one was adjourned) after the outcome of the criminal proceedings is communicated by the appropriate officer of the court or where the coroner is informed that there is to be no prosecution.

This approach reduces the number of cases which may eventually lead to a verdict of unlawful killing in a coroner’s court although some notable exceptions include:

  • cases where the suspect has not been found by police;
  • cases where no charges are made, the inquest is held but unexpected evidence is given that obliges the coroner to adjourn and notify the CPS;
  • cases where the CPS consider the matter but does not consider that the evidence is sufficient to support a charge of unlawful killing/homicide;
  • cases where a death appear not to be suspicious at first, but evidence subsequently is found to give grounds for suspicion of homicide.

Prosecutors may be present during inquest hearings where unlawful killing conclusions have been found, or may be contacted by bereaved family members, the police or the Coroner.

Narrative conclusions

Coroners or a jury may also deliver a 'narrative' conclusion which sets out the facts surrounding the death in more detail. This longer explanation will include the coroner's or jury's conclusions on the main issues arising in the surrounding circumstances of the death. The Coroner is also not bound by the list of suggested conclusions above; this means that as long as the Coroner can form a conclusion which is concise and indicates how the deceased came by their death, a narrative verdict is acceptable. The Coroner is unable to apportion any blame or civil or criminal liability of another individual (as defined by section 10(2) of the Coroners and Justice Act 2009).

Coronial jurisdictions

Coroners will conduct inquests into a death where the deceased's body is lying in their district (geographical 'jurisdiction'); prosecutors should note the provision in the Coroners and Justice Act 2009 brought into force, by Commencement Order No.11, Order 2013 allows greater flexibility for a Coroner to conduct an inquest in another district.

Where a body has been washed ashore, the death will be investigated by the Coroner for that district; where multiple bodies have been washed ashore in different locations, the Coroners for those districts will agree between themselves that a 'grouped inquest' might be the best course of action.

Where a death has occurred aboard an aircraft, the Coroner residing within the district where the aircraft lands will hold the inquest, regardless of where the aircraft was located when the death occurred. A body returned from abroad will usually be dealt with by the Coroner in the jurisdiction where the body is to be buried or cremated.

Coroners will also hold inquests where the death may have occurred abroad and the body is repatriated, and will usually take place in the jurisdiction where the deceased lived before their travel.

Inquests for destroyed or irrecoverable bodies

Where there has been destruction of a body - by fire for example - or where the body may be irrecoverable (such as 'lost at sea') an inquest will be held as defined by section 1 of the Coroners and Justice Act 2009. The Coroner is required to apply to the Secretary of State for permission to hold an inquest, who will direct whether the Coroner should proceed; in these circumstances, the inquest will be treated as an inquest where body does not lie within the coroner's district.

The coroner has to provide evidence to the Secretary of State that a death has actually occurred; it is not sufficient for there to be a 'suspicion' of death, upon the disappearance of an individual (for example, a leg washed ashore would not be sufficient to amount to a suspicion of death; however if a rib case or skull were to be found in the same circumstances, there is a stronger case of certainty of death). The Coroner may also have to prove the body has been destroyed or lies in a place from where it cannot be recovered as well as meeting the criteria required for an inquest.

Inquest juries

The Coroner will often sit alone to hear an inquest, but there are certain circumstances (as defined by section 7 of the Coroners and Justice Act 2009) which place a requirement upon the Coroner to summon a jury to hear an inquest case:

  • the death occurred in prison or similar place of detention;
  • the death occurred whilst the deceased was in police custody, or resulted from an injury caused by a police officer(s) in the purported execution of his/her duty;
  • the death was caused by an accident, poisoning or disease reportable to the relevant Government Department or inspector appointed under section 19 of the Health and Safety at Work etc Act 1974;
  • the death occurred in circumstances where the continuance or reoccurrence of these circumstances is prejudicial to public health and safety;
  • the death was unnatural;
  • the death was sudden or unexpected; or,
  • the death was in other suspicious circumstances.

Attorney General's order to hold an inquest

The Attorney General, under the Coroners and Justice Act 2009 (Consequential Provisions) Order 2013, has a public interest function independent of the Government, to decide whether to apply to the High Court for an inquest. The Attorney can apply for an inquest to be held where either a Coroner had previously refused or neglected to hold an inquest where it ought to have been held, or, where an inquest has been held, and it is in the interests of justice that another inquest should be held. (Examples include the Attorney's decision to request a new inquest for the victims that were killed at the Hillsborough Football Stadium in 1989; and, the decision not to apply for a new inquest into the 2003 death of Dr David Kelly, a government scientist.)

The Attorney has no power to order a new coronial inquest; they can only be ordered by the High Court on an application made either by the Attorney General or by a third party with the consent of the Attorney General. However, before the application can be made, the Attorney has to be satisfied there is sufficient admissible evidence to persuade the Court of either of the two tests set out in section 13 the Order.

Article 2 inquests: 'Jamieson' inquests and 'Middleton' inquests

Article 2 inquests are enhanced inquests held in cases where the State or 'its agents' have 'failed to protect the deceased against a human threat or other risk' or where there has been a death in custody. Cases where the deceased has been under the care or responsibility of social services or healthcare professionals are also often included in this category of inquest.

Article 2(2) of the European Convention of Human Rights (ECHR) - the right to life - states that:

'Deprivation of life shall not be regarded as inflicted in contravention of this Article when it results from the use of force which is no more than absolutely necessary:

  1. in defence of any person from unlawful violence;
  2. in order to effect a lawful arrest or to prevent the escape of a person lawfully detained;
  3. in action lawfully taken for the purpose of quelling a riot or insurrection.'

Article 2(2) is not confined to intentional killing but includes deliberate use of force which has the unintended consequence of causing loss of life. This provision requires the State to take appropriate steps to safeguard life; where there are questions around this specific issue, it is likely that a Coroner will hold an 'Article 2' inquest.

'Jamieson' and 'Middleton' inquests as they are sometimes known, consider neglect on the part on of an individual, and system neglect, under Article 2, respectively.

Jamieson inquests

Inquests where the Coroner will consider whether a lack of care or common law neglect has led to the cause of death of the deceased are often termed as 'Jamieson inquests' and are based on the case of R v Coroner for North Humberside and Scunthorpe, Ex p Jamieson [1995] QB 1.

It is common for such inquests to be heard where the death occurred in a medical context, or where the deceased was in police or other custody immediately prior to his/her death (including where a suicide has taken place).

Prosecutors should note that in Jamieson, the Court of Appeal concluded that in cases where an individual has taken their own life, a conclusion of suicide will usually be recorded as opposed to lack of care or neglect that attributed to the individual committing suicide.

Coroners will not normally use neglect or self-neglect to form any part of their conclusion, unless a clear and direct causal link is established between the conduct described, and the cause of death.

Middleton inquests

Coroners may resume inquests where the State's agents have been involved following criminal proceedings, for example, such as in R (on the application of Middleton) v HM Coroner for Western Somerset [2001] EWHC Admin 1043. The involvement of the State was raised in this case when the inquest jury communicated to the coroner that an agent of the State (in this case, the Prison Service) had failed in its duty of care to the deceased. The deceased had hanged himself in prison, and whilst he had been identified as at risk the proper safeguards were never put in place.

Since Middleton there have been a small number of cases which illustrate other examples of State involvement and will be of interest to prosecutors. In R (on the application of Christine Hurst) v HM Coroner for Northern District of London [2003] EWHC 1721 Admin the deceased was killed by a man known to be violent and potentially mentally ill, and was someone he had given evidence against in eviction proceedings. It was argued the police and local authority could have foreseen the incident and that it was preventable, as both bodies were aware the victim (Hurst) was in danger from his eventual killer (Albert Reid convicted of manslaughter in 2001). Additionally, in Osman v UK (1998) 29 EHRR 245, had the authorities done all that was reasonably expected of them, they could have avoided the threat to the life of an individual of which they had, or ought to have had knowledge. In this case the individual was known to the police and education authorities to have been harassing and threatening students and their parents; he went on to kill one of the student's parents and a teacher at the school.

In cases involving the State in this way, prosecutors may be called to give evidence on the role of the CPS at inquests and should comply with the coroner's request. The most typical scenarios include where there has been a CPS decision not to charge a suspect or where the prosecutor has not contested a bail application, and the suspect has subsequently killed the deceased. Although there will be no direct involvement of the CPS in the death, there may be a need for the CPS to appear as a witness/party in an Article 2 inquest, as a result of the peripheral involvement. This section should be read in conjunction with ‘When a prosecutor receives a Coroner's summons’ to an Article 2 inquest below.

Where an Article 2 inquest is linked to civil proceedings (for example, litigation for damages), prosecutors should inform their line management and Chief Crown Prosecutor, or equivalent, to ensure the necessary steps are taken to handle the proceedings.

Pre-inquest reviews/hearings

Coroners may hold pre-inquest reviews (or hearings) in more complex cases, with the aim of assisting their inquest preparation. There is no statutory authority or set procedure for the hearings; they are held in the same manner as an inquest – in an open court, (and therefore in most instances open to the public), and will provide interested persons the opportunity to be present and to hear the relevant issues.

A Coroner may contact the CPS to attend a pre-inquest review/hearing. There is no obligation for a prosecutor to attend these hearings, unless there is a business need to do so.

Inquest adjournments

Prosecutors should refer to ‘CPS role during inquest adjournments’ for further detail alongside this section.

Where suspicion arises that the deceased's death was caused by a criminal act, the Coroner will open an inquest, and then adjourn it until the conclusion of any criminal proceedings has been finalised, sine die (without fixed date). The CPS will be involved with Coroners' adjournments where there is cause to believe that the death of the deceased was as a result of:

  • a suspicious death (murder, manslaughter, corporate manslaughter (as inserted by the Corporate Manslaughter and Corporate Homicide Act 2007) or infanticide);
  • a road traffic fatality where the offence committed caused the death of the deceased (as defined by sections 1, 2B, 3ZB and 3A of the Road Traffic Act 1988); or
  • under section 2(1) of the Suicide Act 1961 (as amended by section 59 of the Coroners and Justice Act 2009) which defines the criminal liability for complicity for another's suicide (encouraging or assisting the suicide or attempted suicide of another person); or
  • an offence under section 5 of the Domestic Violence, Crime and Victims Act 2004 (causing or allowing the death of a child or vulnerable adult).

These circumstances are all outlined under paragraph 1(6) of Schedule 1 of the Coroners and Justice Act 2009. The Act at Schedule 1 requires the Coroner to adjourn an inquest as follows:

  • paragraph 1(2)(a) of Schedule 1 - Coroners and Justice Act 2009: The Coroner must suspend an investigation or inquest following a prosecuting authority's request on the grounds that a person may be charged with a homicide offence involving the death of the deceased (as outlined under paragraph 1(6) of Schedule 1 of the Coroners and Justice Act 2009).
  • paragraphs 2(1) and 2(2) of Schedule 1 - Coroners and Justice Act 2009: A Coroner must suspend an investigation under this Part of this Act into a person's death in the following cases where the coroner:
  1. becomes aware that a person has appeared or been brought before a magistrates' court charged with a homicide offence involving the death of the deceased, or
  2. becomes aware that a person has been charged on an indictment with such an offence without having appeared or been brought before a magistrates' court charged with it.

Coroner's inquest adjournments

Prosecutors should also read CPS role during inquest adjournments ‘CPS role during inquest adjournments’ for further detail alongside this section.

Coroners can themselves (without external influence) adjourn inquests pending a public inquiry (as set out in paragraph 3 of Schedule 1 of the Coroners and Justice Act 2009) or under Rule 25(4) of the Coroners (Inquest) Rules 2013.

  • Pending public inquiry - A Coroner must suspend an investigation into the deceased's death if it is likely that the cause of death will be adequately investigated by an inquiry under the Inquiries Act 2005. A Coroner may not need to suspend the investigation if there appears an exceptional reason for not doing so.
  • Rule 25(4) Coroners (Inquest) Rules 2013 - Under Rule 25(4) a Coroner must adjourn an inquest and notify the DPP if during the course of the inquest, it appears to the Coroner that the death of the deceased is likely to have been due to a homicide offence and that a person may be charged in relation to the offence.

Coroners are aware the CPS cannot initiate criminal investigations, and will provide the same material to the police. The coroner can discharge this function under Rule 28 in two scenarios:

  1. Where there has been no previous involvement by the police (in relation to a criminal investigation) or CPS following the deceased's death - suspected homicide offence (see also section on ‘Unlawful Killing Conclusions’.

Scenarios where there have been no previous police or CPS involvement are rare, but do occasionally arise.

An inquest may be stopped (adjourned) when the Coroner hears any evidence which gives him/her cause to believe the death may have been caused by an unlawful killing (through the commission of a criminal act). Under Rule 25(4), the Coroner has a statutory obligation to notify the DPP (CPS) the inquest has been adjourned.

Upon referral, the Coroner will contact the relevant prosecutor to arrange for receipt of the relevant material. A prosecutor cannot consider charges from the material received directly from the coroner, but should consult the police who will consider whether an investigation is required. Any decision to investigate by the police, should be communicated to the coroner and CPS.

  1. Cases previously reviewed by the CPS, where no charges have been brought or where charges have been discontinued or terminated.
    Where criminal charges have already been considered by prosecutors and a conclusion of 'no further action', discontinuance, or termination has been reached, the Coroner is free to resume an inquest.

However, the inquest may be stopped (adjourned) when any evidence is heard which gives the Coroner cause to believe the death may have been caused by a homicide offence.

The Coroner's statutory power to refer the case to the CPS will require a prosecutor to consider whether the material needs to be passed to the police. The prosecutor should consider whether any new evidence or information within the Coroner's proceedings has the capability to change any previous CPS decision not to bring criminal charges (that is, any evidence or information which had not been previously available during the CPS' initial consideration). Coroners cannot refer a case for the CPS to reconsider charges based on public interest alone; further evidence is required for a Rule 25(4) referral to be made to the CPS.

The police will determine whether a further investigation is required, and whether a 'fresh' charging decision is needed by the CPS. The police should notify the Coroner and bereaved of the next steps to be taken; prosecutors may also want to ensure CPS Bereaved Families Policy is adopted as required. In these circumstances, the Coroner will adjourn the inquest until the consideration of the charges (if there are to be any) is concluded.

CPS role during inquest adjournments

Where the Coroner is requested to adjourn an inquest under paragraphs 1 or 2 of Schedule 1 of the Coroners and Justice Act 2009, the CPS should ensure the reasons for adjournment (ultimately, that a suspect has been charged in connection with deceased's death) cover the circumstances in which the death occurred, and that this is properly communicated to the Coroner. Where the offence is one other than those listed under paragraph 1(6) of Schedule 1 of the Coroners and Justice Act 2009, the prosecutor should clearly communicate the reason why the coroner should adjourn the inquest.

Prosecutors should note a Coroner can continue with an inquest if notified by the CPS that adjournment is unnecessary. For example, an inquest can run in parallel with the criminal proceedings where there has been a fatal collision and charges have been brought under section 3 of the Road Traffic Act 1988 or any other offence that is not listed in paragraph 1(6) of Schedule 1 of the Coroners and Justice Act 2009 (as above). For road traffic fatalities, this is permitted as section 20(5) of the Road Safety Act 2006 does not apply where the cause of the deceased's death cannot be proved. Further information can be found in the legal guidance, Guidance on charging offences arising from Driving Incidents (see section on Inquests).

It may be beneficial for the reviewing lawyer to attend the inquest, in case the Coroner hears any evidence which questions the original charging decision.

Prosecutors should bear in mind the cases of Re Beresford (Harold) [1952] 36 Cr. App. R. 1 and Smith v DPP & Another [2000] 164 JP 96 which both refer to inquests taking place before criminal proceedings. Smith in particular considers in summary cases it may be beneficial for magistrates to adjourn the criminal proceedings whilst the Coroner holds the inquest; however, there is no absolute rule of law for magistrates to take this action.

Preventing Further Deaths Reports

Following an inquest the Coroner can make recommendations to prevent future deaths from occurring, previously known as a 'Rule 43 Report' but now known as a 'Preventing Future Deaths Report' or 'PFD Report' (as set out in paragraphs 28 and 29 of the Coroners (Investigations) Regulations 2013. The respondent is given 56 days to reply in writing, giving details of actions that have been taken or proposed to be taken, or an explanation as to why no action will be taken to prevent future similar deaths. Copies of all responses will be sent to the Lord Chancellor, who may publish the response or a summary of it, unless the Coroner has exercised his/her power to request a restriction to the publication to the Chief Coroner (under paragraph 29(10) of the Coroners (Investigations) Regulations 2013).

The CPS regularly receives requests to respond to Preventing Future Deaths Reports; prosecutors are asked to notify their CCP/DCCP if a Report is received. It is likely the CCP or even the DPP will also have been sent the Report and arrangements will be put in place to liaise with the appropriate prosecutor in preparing a response.

Coroner's power to summons witnesses at inquests

Coroners have the power to call witnesses to appear at an inquest, and to determine the evidence to be heard. It is the general duty of every citizen (under common law) to attend an inquest if they are in possession of any information or evidence that details how a person came to their death. Notification to appear as a witness will generally be informal, but a Coroner can issue a summons where a witness absents themselves without explanation. Summonses are issued under the Coroner's common law powers and are governed by the directions set out in the Civil Procedure Rules.

Coroner's can issue two types of summonses: requiring attendance to give oral evidence, and requiring attendance to produce documents. All witnesses who are competent can be compelled to attend a Coroner's Court; a person cannot refuse to be a witness because they fear their evidence may lead to them being charged with an offence connected with the death of the deceased. Once sworn in, a witness may refuse to answer any questions put to them on the grounds of self-incrimination (Rule 22 - Coroners (Inquests) Rules 2013.

When a prosecutor receives a Coroner's summons

Prosecutors may be invited by the Coroner to attend an inquest and can be summonsed if their absence has not been agreed by the Coroner. The prosecutor's likely involvement will be peripheral or may not be relevant at all to the inquest hearing. Prosecutors should note there are two types of inquest they may be called to appears as a witness, each with different responsibilities for the CPS. Prosecutors should in the first instance clarify with the Coroner the type of inquest that will be heard and how their evidence will be relevant to the inquest proceedings.

Standard inquests

Prosecutors should decline invitations to attend standard inquests on the grounds that their evidence would not necessarily be relevant to be heard during the inquest.

However, where an invitation is declined, it is possible that a Coroner will summons a prosecutor to appear; where this happens, the prosecutor should verify with the Coroner how their appearance would be relevant to the determination of how the deceased came about his/her death. Prosecutors may find they are summonsed to explain why a charging decision was not made despite being the case being (in the Coroner's view) in the public interest, or why delays (to the progress of a prosecution case) have occurred in more complex cases. Prosecutors should contact the Coroner and explain why the summons does not apply, and explain why the delays have occurred in writing.

Where the coroner insists that a prosecutor needs to comply with the summons request, a prosecutor should consider applying to have the summons set aside formally. Prosecutors should make an application to the coroner under Paragraph 1(4) Schedule 5 of the Coroners and Justice Act 2009.

Article 2 inquests

A prosecutor may receive an attendance request or summons to appear in front of an Article 2 inquest; compliance is essential where the CPS has been involved in the events that led to the death of the deceased. For example, a typical scenario may arise where a CPS decision not to charge a suspect or where a bail application was not contested led to a suspect subsequently killing the deceased.

There may be a need for the CPS to appear as a witness/party in an Article 2 inquest, as a result of this involvement. Despite the involvement being of a peripheral nature, prosecutors need to comply with the Coroner's request as directed.

It is essential the prosecutor's line management and CCP, or equivalent, is made aware of such proceedings. Civil proceedings may also be instituted by the bereaved family in these circumstances; it is essential prosecutors inform their line management chain in order to facilitate the best response from the CPS.

Media reporting of inquests and publicity

All inquests are held in public (except in the 'interests of justice or national security'), allowing members of the public and journalists the right to attend.

Coroners are permitted to hold sections of inquests privately (Rule 11 Coroners (Inquest) Rules 2013), although this will only apply to a specific part of the hearing (usually evidence that may prejudice or compromise national security if disclosed into the public domain). Powers for coroners and other judges to hold closed material proceedings are permitted under the provisions of sections 6-11 of the Justice and Security Act 2013.

Reporting restrictions

Typically, the police will inform the Coroner of any reporting restrictions in place as a result of criminal proceedings ongoing and any subsequent impacts thereafter. In most cases, reporting restrictions will be lifted following the finalisation of criminal proceedings, but it is for the police to ensure the Coroner is apprised of restrictions where required for a longer period.

Coroners can impose reporting restrictions to ensure risks to prejudicing the administration of justice are avoided; these include specific powers to prohibit the publication of personal details of any children or young people who appear as a witness. In these circumstances the Coroner should notify the CPS and police.

Section 11 of the Contempt of Court Act 1981 provides that in any case where a court allows a name or other matter to be withheld from the public in proceedings before the court, the court may give directions prohibiting the publication of that name in connection with the proceedings.

For further information on contempt, prosecutors should refer to legal guidance on Contempt of Court and Reporting Restrictions.

Other proceedings

As mentioned above, criminal proceedings will usually be heard and finalised before an inquest is fully heard. Any civil proceedings (for example for damages claims) will normally follow an inquest, as all facts about the cause of death will then be known.

Section 10 of the Work Related Deaths Protocol also states that where the criminal proceedings have been finalised, other regulatory proceedings may take place. It will be for the Coroner and the relevant enforcing authority to decide the order in which the regulatory proceedings and inquest will take place. This process was put in place following the case of R v Beedie (1997) 2 Cr. App. R. 167 where a scenario of 'autrefois convict' (the defendant had been convicted in an earlier prosecution - in this case, brought about by another prosecuting authority) arose, leading to an abuse of process. The Protocol has been designed to ensure effective liaison takes place between its signatories to avoid the problem of double jeopardy arising. Prosecutors should refer to legal guidance on Abuse of Process and to the Work Related Deaths Protocol: Practical Guide for further information.

What should/can be disclosed to the Coroner?

Coroners may request updates on the progress of a case, and there should generally be no obstacle preventing the prosecutor providing an update. Coroners most commonly seek a legal explanation of a CPS charging decision made or question its premise, and as a result ask to see a copy of the MG3. As legal guidance on Disclosure of Material to Third Parties cites, the MG3 should not be routinely disclosed; however, information may be extracted to provide the Coroner with further details where required. Prosecutors should refer to the legal guidance on Disclosure of Material to Third Parties for further information.

Prosecutors should note that the case of Evandro Lagos and HM Coroner for the City of London and Anele Austin [2013] EWHC 423 (Admin) re-affirms the law that the family are not entitled to have the police report. The report is for the Coroner only. Further onward disclosure would be for discussion with the police. (The same principle will apply to disclosure of reports from the CPS).

Legal Professional Privilege (LPP)

Legal Professional Privilege (LPP) extends to confidential communications between a lawyer and client in the usual way and applies to oral and documentary evidence equally in the Coroner's Court. A Coroner has no power to order the production of documents where LPP applies; production can only be compelled through a High Court or County Court summons.

Prosecutors will be aware of the LPP that applies to specific case material and the MG3 - there is no statutory obligation for specific documents to be disclosed to a Coroner unless a summons has been issued. Prosecutors should use their discretion to determine the case information they disclose, but should note that information to be disclosed only needs to be relevant to the Coroner's inquest parameters; there is no requirement to disclose any specific information in statute governing the coroners' conduct.

Additionally, it is possible that a Coroner may read out communications from the CPS or others during the process of an inquest hearing. Unfortunately there is no mechanism to avoid this, but the disclosure of CPS communications may be prevented if the coroner is explicitly told of the restricted nature of the communication at the time it is sent.

Local Safeguarding Children Boards/Panels, Serious Case Reviews and Domestic Homicide Reviews

Local Safeguarding Children Board (LSCB) (as introduced by section 13 of the Children Act 2004) are required to conduct a multi-agency Serious Case Review (SCR) where there has been a serious sexual abuse or impairment to the health and development of a child; or, where a vulnerable adult is experiencing abuse or neglect and has died following a serious incident.

Domestic Homicide Reviews (DHRs) (introduced by section 9 of the Domestic Violence Crime and Victims Act 2004, in April 2011) are multi-agency reviews undertaken following a domestic violence related homicide.

Both reviews look at lessons to be learned from the circumstances of the death; they do not seek to reinvestigate the situation in which the death occurred, nor do they seek to apportion blame. Both SCRs and DHRs should take place following criminal proceedings, but it is possible that a SCR or DHR may have taken place, or be in progress before a Coroner's inquest takes place.

A Coroner can request information from the LSCB as part of their inquest investigation, and it is the responsibility of the Chair of the Board to make the decision as to what should be released. The Chair will usually consult with the agencies involved, and may request to agencies to suggest redactions to any document proposed for release. Given the CPS' role with these panels, it is likely that most information we provide to the Board or Panel will be disclosed; however, prosecutors should redact information if they consider it inappropriate to be disclosed.

It is likely that the Coroner will use the Report issued by the Safeguarding Board or Panel to make recommendations to specific agencies where the death of the individual could have been prevented (under the Preventing Future Deaths Reports).

Prosecutors should note the case of Worcestershire County Council, Worcestershire Safeguarding Children Board and HM Coroner for the County of Worcestershire [2013] EWHC 1711 (QB), which concerns a Coroner's request for the LSCB's draft overview report, as well as the underlying reports. The High Court said that disclosure was permitted only to the Coroner and not to interested parties at any request.

Code for Crown Prosecutors

Coroners often query why charges have not been brought when in their view it is in the public interest to charge a suspect(s). Prosecutors may need to explain the stages of the Full Code Test in detail to reassure the Coroner that thorough considerations have been made.

What happens when criminal proceedings have been finalised?

The Coroner has the discretion to resume an inquest (or not) following the conclusion of criminal proceedings (see paragraph 7 of Schedule 1 of the Coroners and Justice Act 2009); there will sometimes be a resumption of an inquest, despite a suspect being convicted of one of the offences listed in paragraph 1(6) of Schedule 1 of the Coroners and Justice Act 2009. When a coroner resumes an inquest following criminal proceedings, the coroner must ensure the outcome of the verdict is not inconsistent with the relevant criminal proceedings or other reason(s) that the Coroner's investigation had been originally suspended (paragraph 8 of Schedule 1 of the Coroners and Justice Act 2009).

The Coroner is more likely to resume an inquest following criminal proceedings which has resulted in a conviction where Article 2 issues, in his/her opinion need to be explored.

CPS Assistance with Overseas Enquiries

CPS prosecutors are sometimes asked to assist coroners make a request to a foreign authority for particular information even where there is no criminal prosecution in the UK, for example a copy of an autopsy report or to obtain statements from witnesses abroad. This is because in some countries the investigation and evidence gathering process is a judicial not a law enforcement function.

Prosecutors should inform their Area / Casework Division Coroner SPOC of requests from coroners to assist with overseas enquiries.

The Code for Crown Prosecutors

The Code for Crown Prosecutors is a public document, issued by the Director of Public Prosecutions that sets out the general principles Crown Prosecutors should follow when they make decisions on cases.

The Code for Crown Prosecutors

The Code for Crown Prosecutors is a public document, issued by the Director of Public Prosecutions that sets out the general principles Crown Prosecutors should follow when they make decisions on cases.

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Prosecution guidance

This guidance assists our prosecutors when they are making decisions about cases. It is regularly updated to reflect changes in law and practice.

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