The Coroner

Main functions of the coroner

To enquire into the deaths of certain persons:

  1. Violent or unnatural deaths
  2. Cause of death unknown

Registration of deaths by the doctor

No obligation on a Doctor to inform the Coroner of the death

Two legal obligations imposed on a Doctor:

  1. The Doctor must report death to the Registrar of Births and Deaths in cases where the Doctor has attended a person in the person’s last illness and knows the cause of death (Registration of Births and Deaths Act 1953)
  2. The Doctor has reason to believe a criminal offence has taken place

Where the Doctor reports a death to the Registrar, it is the duty of the Registrar of Deaths to report certain deaths received from the Doctor to the Coroner. These are:

  1. the death of any person not attended during his last illness by a Doctor or
  2. death in respect of which the Registrar is unable to obtain the delivery of a duly completed certificate of cause of death or
  3. any death with respect to which it appears to the Registrar from the certificate of cause of death that the deceased was seen by a certifying Medical Practitioner neither after death nor within fourteen days before death i.e.
    1. If the Doctor has not seen the deceased within fourteen days of death but has seen the body after death then the death is reported to the Coroner
    2. If the Doctor has seen the deceased within fourteen days of death but not after death e.g. death occurred in another area whilst on holiday and the Doctor has spoken to another Doctor who has confirmed death then the death is reported to the Coroner
      NB Very unusual for Doctor to issue Certificate without seeing the body
  4. any death the cause of which appears to be unknown of any death which the Registrar has reason to believe to have been unnatural or caused by violence or neglect or by abortion or to have been attended by suspicious circumstances or
  5. any death which appears to have occurred during an operation or before recovery from the effects of an anaesthetic or
  6. any death which appears from the contents of any medical certificate to have been due to industrial disease or industrial poisoning

What should the Doctor do if the Doctor believes that the Registrar of Births and Deaths will report the death to the Coroner even if the Doctor issues a Certificate?

To save relatives delay and frustration, the Doctor should discuss the death with the Coroner. The Coroner may conclude that the Doctor should issue a death certificate e.g. if the Doctor saw the deceased outside the fourteen day period. The Doctor will then issue a certificate in the normal way and the Coroner will send his report to the Registrar. Upon receipt of the death certificate from the Doctor and the report from the Coroner, the Registrar will register the death.

Stillborn child is one issuing from mother after twenty-four weeks but after birth has shown no sign of life. No Inquest takes place but the Coroner informs the Registrar of Births and Deaths.

Organ transplants

Deceased must have left an authority or next of kin must consent

Infant deaths

If at home – report to the Coroner – Police always asked to attend

Removal of tissue

If organs or substantial amount of tissue is removed e.g. for analysis to confirm cause of death, next of kin must be told and given opportunity to request return after analysis

General rule of thumb

The Doctor should only issue a death certificate if the cause of death is natural and the Doctor has treated the deceased in his last illness and has seen the deceased within fourteen days before death and after death. If in doubt, speak to the Coroner.

Post mortem examinations

The Coroner has power to order a post mortem examination even if the relatives do not want a post mortem to take place

Doctors should supply the Coroner with full details of the deceased’s medical history to assist the Pathologist at post mortem

Examples of death certificates

Good Possible Bad
1 (a) Myocardial infarction(b) Coronary thrombosis(c) Coronary atheroma2 DiabetesUrinary tract infection

NB. Paragraphs not denoted in II

1 (a) Old age

NB. How old is deceased?

1 (a) Bronchopneumonia(b) Recent fracture of femur


1 (a) Respiratory failure(b) Chronic obstructive airways disease

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