Investigating sudden death: the role of the coroner

coroner illustrationNicholas Rheinberg, of the Coroners’ Society, explains how the coroner’s function has changed over eight centuries.

For most people, the function of coroner is something only dimly perceived as pertaining to death, with many ascribing a medical rather than judicial purpose to the role.

Not so, though – the newly appointed coroner will be a solicitor or barrister of five years’ standing, rather than a doctor, and will not perform autopsies, a task reserved for the pathologist. In fact, originally, the medieval coroner was not even a lawyer, but a knight.

The Articles of Eyre 

The office of coroner probably existed in Anglo-Saxon times, but not until 1194 was it given something akin to statutory recognition. In September 1194, the Articles of Eyre pronounced that in every county, three knights and a clerk were to be elected to ‘keep the pleas of the Crown’, or custos placitorum coronae, as the Latin wording proclaimed (the modern title ‘coroner’ being a corruption of coronae).

The investigation of death was a secondary part of the medieval coroner’s duty. Principally, he was to preserve the Crown’s revenue, previously a task performed with corruption and ineptitude by the sheriff. The coroner kept a record of forthcoming trials, and when the King’s Justices appeared in the region, typically on a seven-year cycle, the coroner accounted to the Crown for the forfeiture of land and goods that occurred on conviction of a felony. Suicide was the crime of felo de se (self-murder) and, again, the deceased’s goods were forfeited.

Tension existed between Normans and Anglo-Saxons, who were not averse to murder. One function of the coroner was to determine, through a jury recruited from the male members of the community, whether a deceased, who appeared to have died violently, was Norman. If Norman, a fine know as a ‘murdrum’ (hence the word ‘murder’) was imposed on the community, while proof of Englishry (coroners did not exist in Wales until the end of the 13th century) meant that the community escaped punishment.

The community’s duty, through the first finder (obliged to raise the ‘hue and cry’) was to inform the coroner of unnatural deaths. The coroner’s jury would be summoned to participate in an inquest which had the purpose then (and indeed now) of ascertaining the identity of the deceased and how, when and where they had died.

The jurors, being local, may have been able to identify the deceased in whose presence the inquest was held and could examine the body to discover the cause of death, often obvious from the injuries to be seen. By the 13th century, the coroner’s jury was typically restricted to 32 members. Until modern times, the jury was required to view the body. Accordingly, inquests were held promptly; a necessity without refrigeration.

Eventually, the coroner’s role became specialised and from medieval tax collector it evolved into being almost exclusively concerned with unnatural death and death of unknown cause, although duties in respect of Treasure (previously known as Treasure Trove) remain.

Although no longer required to be a knight, most county coroners were elected. However, since 1888, all coroners are appointed by the local authorities in the areas in which they serve. Although the coroner is a judicial officer, the local authority is responsible for funding, rather than the Courts and Tribunal Service.

The modern coroner

From 25 July 2013, the powers and duties of the modern coroner derive from the Coroners and Justice Act 2009. The Act applies to England and Wales (Scotland has a different system, and Northern Ireland’s coronial system has its own Act). The Act created the Office of Chief Coroner, to give the service leadership and to achieve greater consistency in coronial practice through guidance and education.

The Act envisages a three-stage process, involving:

  • Initial inquiries, which may include the coroner ordering a postmortem examination (this does not require the consent of the deceased’s family).
  • If the inquiry stage does not dispel the need for an inquest, the coroner opens a formal investigation. If, following autopsy, the death appears to have been natural, the investigation is discontinued.
  • The third stage, where necessary, is the opening of an inquest, if there remains reason to suspect that the death was unnatural or violent, or occurred in state detention, or the cause remains unknown.

Chief coroner guidance states that usually a date for the full inquest will be set on opening the inquest. In 2016, of the just over half a million deaths recorded in England and Wales, 46 per cent were reported to a coroner, but only just over 7 per cent of recorded deaths led to an inquest.

After opening an inquest, the coroner will direct a full gathering of evidence and will then preside over the subsequent inquest. Thus, uniquely in the legal system, the coroner is not only investigator, but also adjudicator. Although formal, the inquest is not a trial but a public, neutral, fact-finding exercise to determine, as before, the identity of the deceased, the medical cause of death, and how, when and where the deceased died.

Additionally, the coroner records the detail necessary to formally register the death. The coroner calls witnesses to the inquest and examines them on oath. Family members, as interested persons, are permitted to question witnesses either directly or through a lawyer. The coroner’s conclusions (previously the verdict) are recorded in the Record of Inquest (previously the inquisition).

Most inquests are heard by a coroner sitting alone, although some inquests, including deaths in employment and deaths in state custody, are still heard with a jury, consisting of not less than seven nor more than 11 jurors. There is no appeal from a coroner’s findings, although in certain circumstances, a coroner’s conclusion can be overturned on judicial review, and a new inquest ordered.

About the author

Nicholas Rheinberg is the archivist for the Coroners’ Society. Founded in 1846, the society has as its principal objective the promotion of the usefulness of the office of coroner to the public. Nicholas Rheinberg has been a senior coroner since 1992, first in Somerset, and latterly in Cheshire.

See also: Guide to coroner services and coroner investigations

Image: Courtesy of The Lewis Walpole Library, Yale University