Role of the coroner

words: Michael Fern

One basic point has to be made clear when explaining the coroner’s work: despite what television repeatedly suggests, a coroner is not a forensic pathologist.

Although coroners deal with nearly 50% of all deaths in England and Wales, carrying out inquests on 13%, the idea of the TV coroner who also acts as a pathologist and, sometimes, a detective, is a hard one to dislodge.

At the 2016 SAIF Education Day, Catherine Mason, HM Senior Coroner for Leicester City and South Leicestershire, did just that in her very first slide. She instantly killed off the myth for those in the room, asking why a Silent Witness character would be given legal powers.

The coroner’s job

Instead, Mrs Mason explained what actually goes into becoming a coroner in England and Wales, and noted how that has changed. Becoming a coroner now requires five years of post-legal qualification experience; a change from the previous system, which allowed for “medical coroners” without a legal background.

Appointed and funded at local authority level, key to the coroner’s role is that they remain independent judicial officers. There are currently 96 coroner areas in England and Wales, a number which has been falling as full-time jurisdictions absorb part-time ones. Mrs Mason welcomed that for “avoid[ing] delegation of responsibility”.

All of these coroner areas report to the chief coroner, not their local authorities.

Chief coroner

In addition to leading the local areas, the chief coroner’s responsibilities include setting national standards for coroners, developing training – both for coroners and their staff – approving appointments, keeping a register of investigations which pass the one year mark, overseeing transferring cases between coroners, monitoring overseas military death investigations, and reporting annually to the Lord Chancellor.

This last point provides for two points which Leicester’s coroner called particularly important: accountability and transparency. Mrs Mason said it was an improvement that coroners “don’t work behind closed doors”.

That is also the case with the one year limit for investigations – after that point, coroners must pass cases to the chief coroner, who in turn can pass them to the Lord Chancellor, bolstering accountability.

New rules

The chief coroner system is relatively new. Based on the Coroner & Justice Act 2009, it was not implemented until the summer of 2013. Aiming to “put bereaved people at the heart of the investigation”, changes included the creation of the chief coroner and the office that goes with it to govern the service.

The Act also says coroners have a duty to investigate any death in their area where the death is suspected of being violent or unnatural, the cause of death is unknown, or the death occurred while in custody or state detention.

That was found to include those covered by Deprivation of Liberty Safeguards, which can restrict people if that is found to be in their best interests.

Mrs Mason explained how that has led to investigations now being carried out in areas such as nursing homes where there would not previously have been need for one.


Aside from legal changes, technology has had an impact on the coroner’s work. Mrs Mason encouraged the availability and use of non-invasive post-mortem CT scanning (PMCT).

Among the benefits, she said, are a more detailed autopsy without the need to dissect. She pointed to benefits for families, coroners, and police investigations.

However, she added that issues included its expense, with a lack of state funding,
and its limited availability.


In her final points, Mrs Mason echoed the 2009 legislation by putting families first. After summing up the inquest system, she explained its purpose.

Quoting the Ministry of Justice, she said: “Trying to help bereaved people understand the cause of death, in order to help them come to terms with it, is one purpose of the inquest which, while not figuring in the rules, is acknowledged by all coroners.”

Finally, Mr Mason’s talk ended by returning to the more general question of what the coroner does. She summarised the role as: “An advocate for the dead to safeguard the living.”

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