What happens at an inquest: the UK coroner and inquest process explained

Finding out that a death has been “referred to the coroner” is frightening if you don’t know what it means. It doesn’t mean anything suspicious is assumed, and in most cases it doesn’t lead to a full inquest. This guide explains, in plain terms, why a coroner gets involved, what a post-mortem examination involves, what happens if there is an inquest, and what you need to do while it’s ongoing – including whether you can register the death and where to go for support. For what to do in the hours immediately after an unexpected death, see our guide to what to do when someone dies at home.

The practical answer

A coroner is an independent judge – usually a lawyer, sometimes a doctor – appointed to investigate certain deaths. Their job is to establish who died, and how, when, and where, not to find anyone at fault. A coroner’s investigation is a completely different process from a criminal investigation, and being referred to one is not, in itself, a sign that anything wrong has happened (gov.uk: when a death is reported to a coroner).

Your main point of contact throughout will be a coroner’s officer – a member of staff who liaises between you, the coroner, and everyone else involved (police, doctors, mortuary staff, funeral directors). Most families never speak to the coroner directly; the coroner’s officer answers questions, explains what’s happening, and keeps you updated (Ministry of Justice: A Guide to Coroner Services for Bereaved People, January 2020).

Quick summary

Why was a coroner involved?

A death is reported to a coroner – usually by a doctor, the police, or the registrar – when:

• the cause of death is unknown
• the death was violent or unnatural
• the person died in prison, police custody, or another form of state detention, such as being held under the Mental Health Act 1983

This is set out in the Coroners and Justice Act 2009, the main legislation governing coroners, and summarised in the Ministry of Justice’s guide for bereaved people. It covers a wide range of situations, from a sudden death at home with no recent GP visit, to an accident, to a death during a medical procedure – most of which turn out, on investigation, to have entirely natural explanations.

When does a coroner get involved – and what do they do first?

When a death is reported, the coroner’s staff make initial enquiries, often starting with a phone call to the person’s GP. If this confirms a natural cause with nothing unusual about the circumstances, the coroner takes no further role, the GP or coroner’s office notifies the registrar, and you can register the death in the normal way (gov.uk: when a death is reported to a coroner).

If the cause of death still isn’t clear, or there’s reason to think it wasn’t natural, the coroner opens a formal investigation and usually asks a pathologist to carry out a post-mortem examination.

What does a post-mortem examination involve?

A post-mortem is a medical examination to establish the cause of death, usually carried out by a pathologist. It normally involves an internal examination, though in some areas a CT or MRI scan is used instead – this isn’t available everywhere, and you’d need to ask the coroner as soon as possible if you’d prefer it, and may have to pay for it (see the Ministry of Justice’s guide, section 3.3).

A few practical points families often ask about:

• You cannot object to a post-mortem taking place. The coroner doesn’t need your consent, though they will explain their reasons and take account of religious or cultural needs wherever possible.
• You cannot attend yourself, but you can ask a doctor to attend on your behalf – the doctor may charge for this.
• Samples or, occasionally, organs may be retained for further tests such as toxicology or histology. The coroner doesn’t need your permission for this, but must tell you and give you options for what happens to the material afterwards: lawful disposal, return to you, or (with consent) retention for research or training.
• If you disagree with the findings, you can discuss this with the coroner’s officer, and you can arrange and pay for a second post-mortem yourself once the body has been released.

The post-mortem is carried out as soon as possible after the death. If it confirms a natural cause and there are no other concerns, the coroner’s investigation usually ends there and the body is released for the funeral. If it doesn’t – or the death was in state detention – the coroner will need to investigate further, which may mean opening an inquest.

When will you get the body back? Under the law, the coroner has temporary legal control of the body while investigating, but is required to release it for burial or cremation as soon as possible. If the body cannot be released within 28 days, the coroner must, by law, tell the next of kin or personal representative the reason for the delay (MoJ guide, section 2.4).

Investigation vs inquest: what’s the difference?

These two terms get used interchangeably, but they aren’t the same thing.

A coroner’s investigation is the overall process of establishing who died and how, when, and where. Most investigations conclude without an inquest ever being needed – if the cause of death turns out to be natural and there’s no other concern, the coroner’s role ends once that’s confirmed.

An inquest is a formal step within that process: a public court hearing, held only when required by law – because the cause of death is still unknown, the death was violent or unnatural, or the person died in state detention. Not every coroner referral becomes an inquest, and you’ll be told clearly if one is required in your case (gov.uk: when a death is reported to a coroner).

What actually happens at an inquest hearing?

An inquest is a public hearing where the coroner – sometimes with a jury – hears evidence to establish who died and how, when, and where. It’s important to understand what it is not: there is no prosecution or defence, and neither the coroner nor a jury can find anyone criminally or civilly responsible for the death. That’s a matter for the criminal or civil courts, not the coroner (per the MoJ guide’s explanation of the inquest process, section 5.1).

If the coroner finds evidence suggesting someone may be criminally responsible, they can pass it to the police or the Crown Prosecution Service – but establishing blame is never the inquest’s own purpose.

Who’s there: the coroner, a coroner’s officer, any witnesses being called (a doctor, police officer, or anyone present at the death, for example), and – because inquests are public hearings – potentially members of the public and the press. Evidence can be given by video link, and you can bring a friend or family member for support. Some coroners’ courts have a free, independent support service with trained volunteers who can sit with you.

A jury is only required in specific circumstances – most inquests don’t have one. A jury sits when the death happened in prison, police custody, or another form of state detention (unless from natural causes); when it resulted from an accident at work; or when the senior coroner decides there’s sufficient reason. Where there’s a jury, they decide the facts of the case; the coroner rules on matters of law and procedure.

Complex cases may involve one or more pre-inquest review hearings first, dealing with the scope of the inquest, what documents are needed, and which witnesses will give evidence. As a close relative, you’re legally classed as an “interested person,” which gives you the right to see evidence in advance (called disclosure), attend hearings, ask witnesses relevant questions, and give a witness statement if asked.

If you’re asked to give evidence

You’ll give evidence under oath or affirmation, and the coroner will ask questions first, followed by any legal representatives present. You don’t need a lawyer to attend or participate in an inquest – the coroner is there to make sure the process is fair and that you get the chance to ask relevant questions. Legal aid for representation is only available in certain circumstances, most commonly where the state or a public body is also an interested person (an “Article 2” inquest), such as a death in custody (gov.uk: legal aid).

What conclusion does the coroner reach?

After hearing all the evidence, the coroner (or jury, if there is one) reaches a conclusion. The possible short-form conclusions include: accidental death or misadventure, alcohol or drug related, industrial disease, lawful or unlawful killing, natural causes, road traffic collision, stillbirth, suicide, or an open conclusion where there isn’t enough evidence to reach any of the others. In more complex cases, the coroner may instead – or in addition – give a narrative conclusion, setting out the facts in more detail (full list of conclusions in the MoJ guide, section 6.3).

If the coroner identifies something that could prevent future deaths, they must write a formal report – known as a Prevention of Future Deaths report, or Regulation 28 report – to the relevant organisation, which must respond within 56 days setting out what action it will take. These reports are published on the judiciary.uk website.

How long does it take?

There’s no single answer – it depends entirely on the circumstances. If the coroner’s initial enquiries confirm a natural cause, their involvement can be over within days. Where an inquest is needed, it should be opened and, where possible, held within six months of the death being reported, or as soon as reasonably possible after that. Cases that depend on findings from another investigation first – the police, the Health and Safety Executive, or the Prisons and Probation Ombudsman, for example – often take longer. If a coroner hasn’t completed their investigation within 12 months, they’re required to report this, and the reasons for the delay, to the Chief Coroner (timescales set out in the MoJ guide, section 5.2).

The coroner’s office is expected to update you at least every three months during a long investigation, and to explain any delays.

Can you register the death yourself?

Registering a death is normally something you do yourself at a register office within a set legal deadline – but that deadline doesn’t apply in the same way once a coroner is involved. You cannot register the death until the coroner has either discontinued the investigation or completed it, including any inquest, and told the registrar it can proceed (MoJ guide, section 2.5, “When can the death be registered?”). Our guide to how to register a death in the UK covers what’s needed once you reach that point.

If you need proof of the death sooner – to notify a bank, close accounts, or start probate – ask the coroner’s office for an interim death certificate (sometimes called a coroner’s certificate of the fact of death). Most banks, pension providers, and government departments accept this while the fuller process continues.

What support is available

• Your coroner’s officer is your main point of contact and should explain each step, answer questions, and keep you updated on progress.
• The Ministry of Justice’s Guide to Coroner Services for Bereaved People covers the full process in more detail, including what happens if there’s a related criminal investigation or the death was in custody.
• Cruse Bereavement Support offers free bereavement support, including for families going through an inquest – cruse.org.uk.
• The Law Society can help you find a solicitor experienced in inquests if you decide you want legal representation – solicitors.lawsociety.org.uk.
• If you disagree with how your case has been handled, you can raise a complaint with the coroner’s office in the first instance, or, for concerns about a coroner’s personal conduct, with the Judicial Conduct Investigations Office.

If the death happened abroad rather than in the UK, a different process applies – there’s no UK coroner referral in the same way, though a coroner may still need to be involved once the person is brought home. See our guide to repatriation of a body from abroad for what to do first.

What to avoid

Don’t assume a coroner referral means something suspicious happened – in most cases it doesn’t, and the majority of coroner investigations end without an inquest. Don’t try to arrange the funeral before the coroner has released the body; ask the coroner’s officer for a realistic timeframe instead of guessing. And don’t wait to raise concerns or preferences – whether about a post-mortem, faith and cultural needs, or wanting to see the body – the coroner’s office can only take account of your wishes if you tell them as early as possible.

Summary

A coroner’s involvement usually starts with straightforward enquiries, not a full inquest – most cases end once the cause of death is confirmed as natural. Where an inquest is required, it’s a public, fact-finding hearing, not a trial, and you have clear rights throughout as an interested person: to see evidence, attend hearings, and ask relevant questions. Your coroner’s officer is there to guide you through each stage, and an interim death certificate is available if you need documentation before the process concludes. For what comes next, see our guides to registering a death and the funeral planning hub for the steps that follow.