Key messages

• The coroner has a duty to enquire into violent or unnatural death, sudden death of unknown cause, and death occurring while the deceased was in prison.

• The coroner usually sits alone but must summon a jury in some circumstances.

• The inquest is an enquiry, not an adversarial contest, and the coroner is prohibited from making findings of criminal or civil liability against any person.

• 'Unnatural' deaths include those which occur during operation or before recovery from anesthetic as well as events at variance with the expected.

• A finding of 'lack of care' does not signify civil negligence but refers to neglect.

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