When a death is reported to the Coroner

What happens when evidence is gathered and when a body can be released

When a death is reported to the Coroner

Deaths are usually reported to the Coroner electronically by doctors or the police.
The Coroner may ask a Coroner’s Officer to make initial enquiries. This helps decide what needs to happen next.

Since 9 September 2024, there are two possible outcomes;

a death will either be investigated by the Coroner, or
referred to a medical practitioner so the death can be certified

In these cases, the Medical Examiner will review the certification. A Coroner’s Officer will usually contact you on the same day the death is reported, or on the next working day.

We know this process can be worrying, especially if you are concerned about delays to the funeral. We do everything we can to complete enquiries as quickly as possible. If you have questions, you can speak to a Coroner’s Officer.

Deaths that must be referred to the Coroner

The Notification of Deaths Regulations 2019 set out when a death must be referred to the Coroner.

A death must be referred if there is a reason to believe it was due to:

a) there is a suspicion that the person's death was due to

poisoning;
contact with a toxic substance
the use of a medicinal product or drug;
violence;
trauma or injury;
self-harm;
neglect, including self-neglect;
a medical treatment or procedure;
an injury or disease attributable to any employment held by the person during their lifetime.

b)  it is suspected that the person's death was unnatural
c)  the cause of death is unknown
d)  the person died while in custody or in state detention
e) there is no attending medical practitioner to sign a death certificate (MCCD)
f)  the attending medical practitioner is not available within a reasonable time to sign a MCCD
g)  the identity of the deceased cannot be ascertained.

If the Coroner does not investigate

The death certification reforms that came into force on 9 September 2024 changed how some deaths are handled.

If the death did not happen in custody or state detention, the Coroner may decide that:

the death was due to natural causes, and
a formal Coroner investigation is not needed

In these cases, the Coroner will:

send the relevant information and a CN1A form to the attending medical practitioner
copy in the Medical Examiner’s Office
confirm that their legal duty under the Coroners and Justice Act 2009 does not apply

This ends the Coroner's involvement.

What happens next

The attending medical practitioner must refer the death to the Medical Examiner’s Office.

The Medical Examiner will:

review the medical records
speak with you or another family representative
agree on the cause of death for the medical certificate of cause of death

Once completed:

the certificate is sent electronically to the Registrar
you will be told when you can make an appointment to register the death

Questions about a death certificate

If there is no Coroner investigation and you have questions about the death certificate, contact the Oxfordshire Medical Examiner's Office.

If a post-mortem examination is needed

The Coroner only requests a post-mortem examination after careful consideration. In most cases, the examination takes place at John Radcliffe Hospital, Oxford.

The body is usually released for the funeral within two weeks of the death being referred. Your funeral director and we will keep you informed.

Who carries out the examination

routine examinations are carried out by consultant pathologists
trainee pathologists may assist under supervision
pathologists work independently, on behalf of the Coroner

If the police are investigating suspicious circumstances, the Coroner will request a forensic post-mortem examination. This is done by a Home Office pathologist.

In some cases, the Coroner may ask for specialist examinations, such as of the heart or brain. We will explain this to you if it applies.

Tissue retention

Post-mortem examinations often involve the pathologist taking samples from the body for further testing. The testing process can take up to 3 months, depending on what type of analysis needs to be done.

Histology

Histology is the examination of very small pieces of tissue taken during a post-mortem. In most cases, these samples are small. They are usually about the size of a fingernail. The samples are sent to a laboratory, where a pathologist examines them under a microscope.

Organ retention

In a small number of cases, the pathologist may need to keep a whole organ or part of an organ. This allows more detailed testing to be carried out before final conclusions are reached.

Toxicology

Small amounts of blood, urine or other body fluids are taken as part of the examination. These samples are tested for alcohol, medicines or drugs. When toxicology samples are taken, a full screen is carried out in all cases. This is routine and not based on lifestyle or personal circumstances.

How we will contact you

A Coroner's Officer will phone the next of kin, or another agreed family contact, to explain the post‑mortem arrangements.
After the examination, the Officer will call again. They will explain the findings and what will happen next.
If we are unable to contact relatives after making reasonable efforts, the Coroner may need to go ahead with the post‑mortem without first speaking to the family.

Objections to post-mortem examinations and religious considerations

We know that some families do not agree with an invasive post‑mortem examination. We understand these concerns and respect the reasons behind them.
The Coroner must follow the law and apply it fairly in every case. This means the Coroner makes the final decision. In some situations, a post‑mortem may be needed even if the family does not agree.
We know this can be very hard. We will support you throughout the process and do all we can to reduce any delay to funeral arrangements.

Consult the following guidance sheets issued by the Chief Coroner for further information regarding post-mortem examinations and prioritising cases in general.

How to challenge a decision to order a post‑mortem examination

You can contact the Coroner if you want to share more information or explain your views. If you tell us you plan to do this, we will pause the post‑mortem examination. This allows the Coroner time to consider what you have said. We will then speak to you to explain the decision before anything goes ahead.

Delays

You must not confirm a funeral date or book a repatriation flight until the Coroner has completed their enquiries.

We understand you may want to move things forward as quickly as possible. However, repeated phone calls or visits will not speed up the process. We will already be doing everything we can. We recommend that the family choose one person to contact our office. We will keep that person informed of any updates or next steps.

An Inquest without a post-mortem examination

In some cases, the Coroner may decide that an inquest is needed, but a post‑mortem examination is not.
This can happen when the cause of death is clear and not disputed, but the death was not due to natural causes.
For example, this may include a death following a fall, or a death linked to an industrial disease such as asbestos exposure that was diagnosed during the person’s life.
Each case is considered on its own facts. If this applies, a Coroner's Officer will explain the process and walk you through it.