Coroners, post-mortems and inquests

Deaths reported to a Coroner

A death is reported to a Coroner in the following situations:

• a doctor did not treat the person during their last illness
• a doctor did not see or treat the person for the condition from which they died within 28 days of death
• the cause of death was sudden, violent or unnatural such as an accident, or suicide
• the cause of death was murder
• the cause of death was an industrial disease of the lungs such as asbestosis
• the death occurred in any other circumstances that may require investigation

A death in hospital should be reported if:

• there is a question of negligence or misadventure about the treatment of the person who died
• they died before a provisional diagnosis was made and the general practitioner is not willing to certify the cause
• the patient died as the result of the administration of an anaesthetic

A death should be reported to a Coroner by the police, when:

• a dead body is found
• death is unexpected or unexplained
• a death occurs in suspicious circumstances

Doctors

Any hospital doctors, out of hours doctors or GPs wishing to report a death can find the relevant death reporting forms at the following link:

• Coroners Service publications

Fill in the forms and email to:

• deathreportingteam@courtsni.gov.uk

Prison governors

A death should be reported by the governor of a prison immediately following the death of a prisoner no matter what the cause of death is.

Find out how to contact the Coroners Service for Northern Ireland.

After a death is reported

A Coroner will first gather information to investigate whether a death was due to natural causes and if a doctor can certify the medical cause of death.

The Coroner will ask the police to gather the information about the death. This will usually include speaking to the family of the deceased, anyone who was caring for the deceased and anyone who was there when the death happened.

If the reason why a doctor cannot certify the death is simply because they have not treated the patient in the last 28 days, then the Coroner will discuss the cause of death with the doctor. If a Coroner is satisfied that death was from natural causes and no further investigation is necessary, then they may accept the medical cause of death that a doctor gives and issue a Coroner's notification to allow the death to be registered.

If a doctor cannot certify the medical cause of death then a Coroner will investigate the death and may order a post-mortem examination to be carried out.

Identifying the body

If the Coroner orders a post-mortem examination then a member of the family will be asked to formally identify the body. This could be to the police at the place where the death has happened or at the mortuary before the post-mortem examination is carried out.

The Coroner will normally ask the police to tell relatives of the need for a post-mortem examination unless this is not possible or would unduly delay the examination.

The consent of the next of kin is not required for a Coroners post-mortem examination to take place.

The next of kin can be represented at the examination by a doctor of their choice.

Coroners Liaison Officers

Coroners Liaison Officers are people who work for a Coroner to help bereaved families when a post-mortem examination has been ordered.

The Coroners Liaison Officer will contact the family and forward written information to the family about the preliminary cause of death and enclose documents to assist with financial matters.

Find out more about coroner liaison officers.

Post-mortem examinations

A post-mortem examination or autopsy is an examination of the body following death. It is carried out by a pathologist. These are doctors who are experts in finding out the cause of death. The examination is carried out as soon as possible after death and every effort is made to minimise any delay. 

The pathologist will start with an external examination of the body followed by an internal examination. The major internal organs will need to be removed and examined. In most cases the organs are returned to the body afterwards.

Although some information can be obtained from looking directly at organs in a post-mortem examination, often the only way to understand properly what has happened is:

• to look at part of an organ under the microscope
• carry out special tests
• get a second medical opinion

Tissue samples, blocks and slides

It is usually necessary to retain small tissue samples for further examination and for further tests such as looking at chromosomes or genes and searching for infections due to bacteria or viruses that may have caused the death.

Small samples of tissue are removed from the organs and placed in small plastic containers. The samples measure around 1.5 x 1.5 cm (smaller than a postage stamp) and are up to 5 millimetres thick.

The tissue is chemically treated to remove water, which is replaced with wax. This process creates tissue blocks. Very thin slices (sections) a tenth of the thickness of a human hair are then cut from the surface.

The sections are placed on glass slides so that they can be examined under a microscope. More than one slide can be cut from each block.

These techniques are the same as those used to examine tissue from living patients.

The tissue blocks and slides are stored in special cabinets as part of the medical pathology records and in line with the Human Tissue Act 2004.

The process of creating tissue blocks and slides may create very small amounts of unused or residual tissue. This is usually disposed of by incineration.

Occasionally it is necessary to retain whole organs for further examination, as this can provide more detailed understanding of the cause of death.

The next of kin will always be advised if any tissue samples or organs are retained for further tests.

X-rays, photographs and other images

It may be necessary to x-ray or photograph the body or an organ during the post-mortem examination. These images form part of the record of investigation of the death. They are usually retained indefinitely. Their use is strictly controlled and always confidential.

Post-mortem results

The pathologist will provide the preliminary results of the post-mortem examination to the Coroner very quickly. However, a final written report may not be available for some time as further tests may need to be carried out and these can take time to complete.

The Coroner’s Liaison Officer will contact the family as soon as the preliminary results are available and will advise the family on the finding. They will also be able to say if any organs or tissue have been retained following the post-mortem examination.

When the final post-mortem report is completed it will be sent to the Coroner who will forward a copy to the deceased’s doctor. The family will be informed when this happens and they may also request a copy of the final report from the Coroner. The report may contain complex medical terminology, and the family may wish to discuss the findings with their family doctor.

Family members may feel that they would like to discuss the post-mortem examination with the pathologist who carried it out. The Coroner’s Liaison Officer can arrange this.

Retained organs and tissue

The pathologist, with the authority of the Coroner, may need to retain any organs and tissue samples removed at the post-mortem examination to assist in the investigation into the death. Once the Coroner’s investigation has finished, the Coroner will decide if these samples need to be retained or if they can be released.

The Coroner’s Liaison Officer will contact the family to discuss the Coroner’s decision and the options available to them. 

Further use or disposal of organs

The choices are:

• for the organs to be returned through your funeral director - it will be the family’s responsibility to arrange a separate cremation or burial for these organs
• for the Coroner to allow disposal of the organs in a lawful and respectful way by the pathologist
• to allow the organ to be used for teaching and research if this is suitable

Further use or disposal of tissue blocks and slides

Tissue blocks and slides will be stored by the Pathologist on behalf of the Coroner until the Coroner’s investigation is completed and the Coroner decides that these no longer need to be retained.

The Royal College of Pathologists recommends that tissue blocks and slides form part of the medical pathology records and that they should be retained in case they need to be reviewed at a later time. If they are retained, access to them will be strictly controlled and they will not be used for any purpose without permission of the next of kin.

The family can ask for:

• the release of the tissue blocks and slides, and if the Coroner agrees, they can choose for the blocks, slides, and samples for genetic testing to be retained for future use – for example, the wellbeing of future people (including family members), education and training of health care professionals or research approved by an ethics committee if suitable
• the Coroner to allow disposal of the tissue blocks and slides in a lawful and respectful way by the pathologist
• the tissue blocks and slides to be returned through the funeral director

If the family's choice is to have the organs and tissues collected by a funeral director, it will be the family’s responsibility to make the suitable arrangements for a separate cremation or burial of the organs and tissues. This means it may not be possible to have the case more fully reviewed or to seek a second opinion at a later date. If collection does not take place within three months of contact, the hospital will tell the Coroner’s Liaison Officer who will clarify arrangements with the family.

Returning the body

The body will be prepared by the mortuary staff and then released to an undertaker who can make arrangements for family and relatives to view the body. Normally any incisions (cuts) that have been made during the post-mortem examination will not be visible. The funeral director will be able to tell you if there are any visible signs of the examination before you view the body.

The body is normally released immediately after the post-mortem examination. Very rarely, usually in criminal cases, it may be necessary for the pathologist to retain the body for further re-examination. If this is the case, the family will be given information about this and every effort will be made to release the body as quickly as possible.

Death registration and funeral arrangements

If the death was due to natural causes which a doctor is able to confirm, the Coroner will advise the Registrar by issuing a Coroner's notification and the death can be registered and a death certificate issued.

However, if a post-mortem examination is ordered, or, if an inquest is to be held, then the death cannot be registered until the Coroner's investigation has been completed. In these circumstances funeral arrangements should not be finalised until the Coroner has authorised the release of the body for burial or cremation.

When registration of the death is delayed, the Coroner can issue an interim certificate called a ‘Coroner’s Certificate of Evidence of Death’ to assist in the administration of the estate. However, not all financial organisations will accept this and you may need to wait for the final registration of the death before the administration of the deceased’s estate can be completed.

A funeral may take place once the Coroner is satisfied that the body is no longer required for the investigation. The Coroner will release the body to a funeral director of the family’s choice and issue a burial or cremation order. Even if the Coroner is going to investigate the circumstances surrounding the death, the funeral can still take place as soon as the Coroner has released the body.

The Coroner’s Liaison Officer will be able to confirm to you when the Coroner has released the body.

• Registering a death
• Arranging a funeral

Inquests

An inquest is an inquiry into the circumstances of a death. The purpose of the inquest is to find out who the deceased person was and how, when and where they died and to provide the details needed for their death to be registered. It is not a trial.

It is not for the Coroner to decide, or appear to decide any question of criminal or civil liability or to apportion guilt or attribute blame.

A date for the inquest will be arranged when a Coroner’s investigation is complete. Inquests are open to the public and the media.

Coroners decide who should take part to give evidence as witnesses at an inquest. Witnesses will first be questioned by a Coroner, and there may be further questions by ‘properly interested people’ or their legal representatives.  This can include:

• relatives of the deceased
• the executor(s) of the deceased’s will or person appointed as the deceased’s personal representative
• solicitors acting for the next of kin
• insurers with a relevant interest
• anyone who may, in some way, be responsible for the death
• others at some special risk or appearing to a Coroner to have a proper interest

The findings of an inquest will record the essential facts about how the person died.