Coroners services

This section provides information about the role of coroners and inquests.

Coroners and Coronial Services

Coroners are independent judicial officers who investigate violent or unnatural deaths or deaths where the cause is unknown. This is likely to include all road deaths. Coroners are qualified lawyers. They are appointed by the Governor General.

If you are listed as the immediate family, someone from the Coronial Services team at the Ministry of Justice will call you soon after you are told about your loved one’s death.

The purpose of a coroner's inquiry, which may include an inquest, is to find out who has died and how, when and where they died. A coroner's inquiry cannot apportion criminal blame or decide if anyone should be punished. These things are decided through criminal proceedings.

When a coroner opens an inquiry, they will find out the identity of the person who died, and other basic details about what happened.

The coroner is responsible for authorising the release of the body for burial or cremation. Prior to this, and to help find the cause of death, a coroner will often order a post-mortem examination of the body. If, after the post mortem, the coroner is satisfied that a death was due to natural causes, they will usually end their investigation and not hold an inquiry.

If someone is likely to face criminal charges for causing the death, the coroner will postpone an inquiry until these have been dealt with through the courts. At this stage you can request a ‘Certificate of Interim Findings’ if you need one; however if a prosecution is pending, the police and/or prosecuting agencies will be consulted to ensure issuing a certificate doesn’t jeopardise the investigation.

Following any criminal proceedings the coroner can only resume the investigation if they consider that there is a "sufficient reason" for doing so.

In some cases the coroner's inquiry includes an inquest (see below). This will only be held if the coroner believes there are significant issues in relation to the actions of a person and/or organisation that would be best dealt with by a formal court proceeding.

Coroners are assisted by Coronial Case Managers. Part of their role is to give you information, and answer any questions you may have, about the coroner’s inquiry. Your police contact can tell you how to contact Coronial Services, or go to

You can find a full guide to Coronial Services at:


A coroner's inquiry may include an inquest (a public hearing), but only in certain circumstances, for example if they want to hear from witnesses in person. If an inquest takes place it will be held in a court, or occasionally another building such as a town hall. An inquest is always heard before a Coroner without a jury.

If you think a criminal court failed to discuss all the facts relating to why a death happened, you, or a solicitor representing you, can ask the coroner to consider continuing with an inquiry and inquest. The coroner will decide whether they should do this or not. If the coroner continues with the inquiry and inquest after criminal proceedings have concluded, they are not permitted to make a finding that contradicts a finding in the criminal court.

At an inquest, witnesses are usually called to give evidence. The coroner will decide who should give evidence. This may include the police, medical staff, expert witnesses and eye witnesses. Contributions may also be allowed by a relative or friend of the person who has died. There may be particular people who you, or a solicitor representing you, think are important witnesses. If so, you or your solicitor can suggest these people to the coroner. Anyone who may face, or who has faced, a criminal charge in connection with your case can be required to attend the inquest and be sworn in as a witness and face questions, although they have the right not to answer questions that may incriminate them.

Once witnesses have given evidence to the coroner, they may also be questioned by other people, known as ‘interested parties’. This could be you, or someone else close to the person who died, or a solicitor representing you. All questions must be about the facts of the death. The coroner will decide whether a question is relevant.

A coroner may also allow a lawyer representing someone accused of a criminal offence in connection with the crash to ask a witness questions about the facts of the death.

The coroner will then reach a conclusion that states who died, and where, when and how they died.

If a coroner believes action should be taken to prevent future deaths, they can also include comments and recommendations in their final report. They send this report to any relevant organisation or individual who may be able to address these issues. They have the opportunity to respond to those recommendations before the report is finalised. The coroner cannot force anyone to take steps to prevent future deaths. You will also usually receive a copy of the findings report. A final notification is also sent to Births, Deaths and Marriages so that a death certificate can be issued. The finding is a public document and the public can request to see it. Findings of particular public interest can be published on the Coronial Services website -

Attending an inquest

Inquests are public hearings so you can attend if you want to. You may wish to, and are allowed to, have legal representation at an inquest. See above for information about the role of a lawyer at an inquest and read more information about hiring a lawyer in the Practical Issues section of this pack.

The Coronial Case Manager should inform all interested persons (which include the next of kin) of the date, time and venue of an inquest. If you are not told, you can ask the case manager.

For most people, attending an inquest is a new experience. You may wish to familiarise yourself with the courtroom in advance by visiting it. The Coronial Case Manager can arrange this.

Before an inquest, you, or a solicitor acting on your behalf, can request to see documents such as reports that are going to be presented at an inquest, to help you, or your solicitor, prepare for the inquest. You are allowed to see relevant documents but sometimes a coroner decides a document cannot be shared for legal reasons.

During the inquest, technical terms may be used. Coroners should try to explain terms so you can understand what is being discussed. You may find some evidence upsetting, for example descriptions of injuries or photographs. If you get upset during an inquest, you can leave the courtroom. If you leave, the coroner may be prepared to adjourn the inquest for a short time to allow you to recover and so you do not miss any part of the inquest.

After an inquest is over, it is possible for you, or your solicitor, to request a copy of the hearing transcript. Before deciding whether to listen to the recording you may want to find out what it contains, in case there is anything you don’t want to hear because it may distress you. You are not permitted to copy or publish the recording without permission from the coroner.

Because inquests are held in public, someone who may have caused the death, and their family or friends, may attend. Journalists may also attend and report on what happens if the coroner gives permission. Journalists may also ask to talk to you. You may wish to ask family or friends, or a Victim Support volunteer, to attend the inquest with you for support. The Coronial Case Manager can tell you how many seats will be available and reserve seats at the front of the courtroom for you.

A guide to the coroner inquiry process, including the inquest, is available at Also included are the standards you can expect to receive from a coroner's office and what to do if you feel those standards have not been met.

Victim Support volunteers can offer emotional and practical support to you before and during an inquest, and can offer guidance on procedures in the court. To find out more call 0800 842 846 or visit their website

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