Legal background

Coroners in England and Wales are judicial officers with at least 5 years professional experience as medical practitioners, barristers, or solicitors. They are appointed by local authorities but thereafter can only be removed from office by the Lord Chancellor. Their role and responsibilities are defined by Statute, supplemented by the body of decided cases which constitutes common law. Their primary remit is to enquire how, when, and where a person has died when there is reasonable cause to suspect:

1. the deceased has died a violent or unnatural death;

2. has died a sudden death of which the cause is unknown;

3. has died in prison or in such a place or in such circumstances as to require an inquisition under any other Act.

The Coroners Act 1988 confers statutory power which can be invoked to compel a coroner to hold an inquest or, in some circumstances, to quash the findings of an inquest and order a rehearing. The proceedings of a coroner's court are also open to judicial review, a process by which procedural irregularities can be explored and rectified.

Unlike a criminal prosecution or a civil suit for negligence, the coroner's inquest is an enquiry, not an adversarial contest. Indeed, there is a specific requirement to avoid any finding which might appear to determine any question of civil or criminal liability. No witness can be compelled to answer any question tending to incriminate himself, but any person whose conduct is likely, in the opinion of the coroner, to be called into question is either summoned as a witness or must be notified of the date, time, and place of the hearing. Furthermore, the coroner is required to adjourn an inquest if requested to do so by the Chief Officer of Police or by the Director of Public Prosecutions on the grounds that a person may be charged with murder, manslaughter, or infanticide, of causing death by dangerous driving, or of aiding, abetting, counselling, or procuring the suicide of the deceased. If evidence given during an inquest suggests that such a charge might be made, the coroner is required to adjourn the hearing and refer the papers to the Director of Public Prosecutions.

The coroner usually sits alone, assisted by a coroner's officer who is often a former police officer. The coroner may summon a jury for any inquest, but must do so in the following circumstances:

1. any death occurring in prison, even if entirely natural;

2. if the death occurred while the deceased was in police custody or resulted from an injury inflicted by a police officer in the purported execution of his duty;

3. where an inquest is to be held in any event and the death was caused by an accident, poisoning, or disease which requires notification;

4. if the death occurred in circumstances which, if continued or recurring, would be prejudicial to the health and safety of the public.

Unlike the 12-person jury of the criminal courts, a coroner's jury consists of not less than seven and not more than 11 jurors. Proceedings are usually slower and more formal in the presence of a jury; it is they who will make findings of fact, but only after the coroner has summarized the evidence and directed them upon the law.

There was a time when the coroner or the jury were empowered to add a rider to the verdict making recommendations designed to prevent recurrence of similar fatalities. That power no longer exists, but the coroner is still entitled to report such matters to those in a position to take appropriate action.

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