Charter for Coroner Services
This document describes the standards of the Worcestershire Coroner’s Service.
It covers procedure before, during and after inquests, post mortems, the role of jurors, treasure and how to give feedback and make complaints.
Click on the questions below to see the answers.
Section 1 – General standards that you can expect during a coroner's inquiry
1.1 The coroner's office will, on request:
- explain the role of the coroner;
- try to help you understance the cause of death of the person who has died (but will not be able to give any legal advice);
- explain, where relevant, why the coroner intends to take no further action in a particular case;
- answer your questions about coronial procedures as promptly and effectively as possible;
- provide you with contact details for the office i.e. a named individual with his or her phone number and email address;
- inform you of your rights and responsibilities;
- take account where possible of your wishes, feelings and expectations, including family and community preferences, traditions and religious requirements relating to mourning, post-mortem examinations and to funerals;
- unless otherwise agreed, contact you at least every three months to update you on the progress of the case, explain reasons for any delays;
- have respect for individual and family privacy;
- treat you with fairness, respect, dignity and sensitivity;
- treat children and young people involved in an inquiry in a way appropriate to their age;
- make reasonable adjustments, where possible to accommodate the needs of those with disabilities;
- help you find further support where this is needed; and
- give you information about how to make a complaint about a coroner's conclusion or if a particular service is not delivered.
1.2 You should:
- co-operate fully with the coroner's office and provide promptly all information that is relevant to the inquiry;
- treat with confidence any information or documents that the coroner's office discloses to you;
- inform the coroner's office as soon as possible of any relevant considerations for the inquest, e.g. a disability, so that reasonable adjustments can be made;
- inform the coroner's office of any change of circumstances, such as change of address or contact number, so you can be contacted promptly;
- inform the coroners office of any concerns or worries you may have about death;
- dress appropriately for the inquest;
- treat the coroner and his or her officers and other staff with courtesy; and
- in the case of bereaved family members, nominate an appropriate representative as the 'next of kin' for communication with the coroner's office. (See section 3 of this Charter for more details.)
1.3 If you are a bereaved family member, you may wish for someone to support you through the inquiry
process, and liaise with the coroner's office where appropriate. (The representative may be someone such as a
friend or relative, a legal advisor or a member of a support organisation.) If so you should discuss this with
the coroner's office as soon as possible to agree how best to proceed.
1.4 Other properly interested persons and witnesses may also wish for support.
You should discuss this with the coroner's office.
1.5 Useful information for everyone involved in a coroner's inquiry is available from Directgov:
What To Do After A Death
1.6 The coroner's office will be able to provide information on the main local and national voluntary bodies, support groups and faith groups which help people who have been bereaved, including as a result of particular types of incidents or circumstances, or specific medical conditions.
The NHS Choices website also contains details of support organisations: NHS Choices.
Section 2 – Overview of the coroner inquiry process after a death is reported
(NB: This flow only applies in non-criminal cases. Where there is a criminal case, the inquest may be opened
and adjourned until the outcome of the criminal trial, and in such cases the coroner's office will explain
Coroners Inquiry Process Diagram
Section 3 – Standards properly interested persons can expect throughout the inquiry process
3.1 When a death is reported to the coroner, the coroner's office will contact the next of kin, where known, and where possible, within one working day of the death being reported, to explain why the death has been reported and what steps are likely to follow.
3.2 Where viewing arrangements are available at the mortuary, the coroner's office will give the next of kin information, as soon as possible, on arrangements for viewing the body, if they wish to do so. In all cases, the coroner's office will advise the next of kin or their representative of the procedure for viewing the body.
3.3 Where a coroner directs or requests a post mortem examination, you can ask the coroner's office to tell you when and where it will be performed, unless it is impracticable to do so or would delay the examination. See the Guide (paragraph 7) for more information.
3.4 If you wish to be represented at the examination by a doctor, you should inform the coroner at the earliest opportunity. If you have queries or are unhappy with the decision to hold a post-mortem examination, you should let the coroner's office know as soon as possible. However, it is the coroner who is responsible for deciding whether or not to hold a post-mortem examination.
3.5 When the coroner requests additional scientific examination of material, his or her office will inform you, if possible. Additional examination may be needed to assist with establishing the cause of death or, rarely, the identity of the person who has died. Again, if you have queries or concerns you should direct these to the coroner's office at the earliest opportunity. However, the coroner is ultimately responsible for deciding whether these examinations should take place.
3.6 In the unusual event of the coroner agreeing to a request for a further post-mortem examination (for example, in a case of suspected murder) you may express any concerns to the coroner. However, it is the coroner who is responsible for deciding whether to request the second examination.
3.7 If the coroner decides not to request a post-mortem examination, and you wish to challenge the decision, you should discuss this with the coroner's office. However, it is the coroner who is responsible for deciding whether or not to hold the post-mortem examination.
3.8 You have a right to request copies of reports of any post-mortem examinations carried out. You may, however, find the details distressing. The coroner's office may charge a fee for copies of documents that have been used in an inquest, but may not charge for disclosing documents before an inquest. A fee will also not be payable where a coroner permits a properly interested person to come to the coroner's office and inspect the post mortem examination report. See the Guide (paragraph 8) for more information.
3.9 Different arrangements may apply in the event of certain types of deaths. In such cases, the coroner's office will explain the arrangements to you. See section 4 for some examples.
3.10 The coroner is entitled to have possession of the body until the inquest is concluded, though almost always releases the body earlier.
3.11 Once the coroner no longer requires the body for his or her inquiry he or she will retain the body only with the consent of the family, except in exceptional circumstances. An example would be where there is a dispute about to whom the body should be released. Arrangements may vary where there is a criminal investigation into the death. See paragraph 4.5 below for details.
3.12 Sometimes material is retained for additional examination. In this instance, the coroner will notify the appropriate next of kin of this and ask them what they wish to happen to the organs or tissues when he or she no longer requires them. See the Guide (paragraph 10) for more information.
3.13 If an inquest is required, meaning that the coroner continues his or her inquiry
following the post-mortem examination, the coroner's office will usually contact you at least every three
months to update you on the progress of the case. This will not apply if you have indicated that you only
wish to be contacted when there is progress to report. You may also contact the coroner's office for an update.
3.15 The coroner's office will, wherever possible, take your views into account on the timing of the inquest. The office will also be able to give you information for example, the purpose of the inquest, others who may be present, and how you can participate in the proceedings, for instance by addressing the coroner directly or through a legal or other representative.
3.16 If the date or location of the inquest has to be changed, the coroner's office will let you know as soon as possible.
3.17 In advance of the inquest, the coroner's office will normally be able to disclose to you, on request, relevant documents to be used in the inquest. You should be aware that for legal reasons the coroner may not be able to disclose all the documents or part of the document he or she intends to use at the inquest. The coroner will be able to explain why he or she has not disclosed a particular document, or part of a document. See section 3.8 for more details on disclosing documents.
3.18 Where the coroner decides to hold a pre-inquest hearing, the coroner's office will tell you the time, date and location of the hearing and the purpose of the hearing.
3.19 As an inquest is a formal occasion it is advisable to dress quite smartly but comfortably.
3.20 Some coroners arrange for the Coroners' Courts Support Service, or other similar services, to be present on days when they hold inquests. If so, the support service will welcome you on arrival at the inquest, explain the process where needed – working jointly with the coroner's office – and answer any queries you may have before and immediately after the inquest.
3.21 Some inquest venues may have a room that you can use as a private waiting room. If so, the coroner's office will advise you of this.
3.22 Except in rare circumstances where national security issues are raised, inquests are held in public. The media therefore have a right to attend and may report inquest proceedings. The coroner's office will not release any information to the media which has not already been made public through an inquest, without the consent of the next of kin. You may wish to read the Editor's Code of Practice, administered by the Press Complaints Commission. This code sets out the ethical standards that all members of the press should meet. See the Guide (paragraph 24) for more information.
3.23 You may ask witnesses relevant questions at the inquest, or have a legally qualified representative do so on your behalf. You may also have a non-legally qualified representative speak on your behalf, if the coroner so agrees.
3.24 If you wish to ask a question (either yourself or via a representative) the coroner will decide whether the question is relevant or otherwise proper. When asking a question you should bear in mind that the purpose of the inquest is to establish the relevant facts of the death and not to apportion blame.
3.25 If the coroner writes a report to prevent future deaths (known as a "Rule 43" Report) at the end of
the inquest the coroner's office will send you a copy of the report, and any reponse, or a summary of the response which the relevant
person or organisation makes . (see the Guide(paragraph 23) for more information or download the guidance on Rule 43 at
Rule 43 Guidance). If the organisation does not respond within 56 working
days the coroner will follow up the matter with the person or organisation, and may inform the Lord Chancellor of a failure to
respond to the report. A summary of reports by coroners to prevent future deaths and responses from organisations is also published
twice a year on the Justice website at
Section 4 – Inquiries where the process may be different
4.1 If the coroner decides to transfer an inquiry to a different coroner, he or she will inform you of that decision and the reason for it. The coroner's office will consult you beforehand wherever possible.
4.2 A coroner inquires into a death that occurs abroad if the body is brought back into his or her district and the apparent circumstances of the death would have led him or her to do so had the death occurred in England or Wales.
See the Guide (paragraph 13) for more information. The standards of service outlined in this Charter, in particular (but not exclusively) in relation to post-mortem examinations and inquest hearings, may need to be varied
because of the additional administrative difficulties in receiving information from overseas.
4.3 For deaths of service personnel on operations overseas, the coroner will usually request a post-mortem examination. The coroner will also usually conduct an inquest into the death.
The procedures may vary for service personnel killed on operations overseas and the coroner's office will provide you with more information.
4.4 When someone under the age of eighteen dies, the coroner must, within three working days of the date on which the coroner decides to hold an inquest or request a post-mortem examination, ensure the appropriate Local Safeguarding Children Board (LSCB) knows of the death.
Coroners share information with the appropriate LSCB for the purposes of carrying out their functions of investigating the death of the child and undertaking Serious Case Reviews.
4.5 Where there is a criminal investigation into the death, there may be a further post-mortem examination. The coroner will make every effort for this decision to be taken as soon as possible, and the body will be released for burial or cremation at the earliest opportunity. If, however, no charges have been made in connection with the death within 28 days of the discovery of the body, the coroner will arrange a second post-mortem examination by a pathologist independent of the first, to be used by an future defence.
The body will then be released at the earliest opportunity.
4.6 Where there is a criminal trial against a person for causing the death, by murder or manslaughter, the coroner will open and adjourn the inquest until the criminal trial is over.
4.7 When the criminal trial is over, the coroner will decide whether to resume the inquest. The coroner's office will be able to provide more information on the process. See the Guide (paragraph 15) for more information.
Section 5 – Feedback, challenging a coroner decision and complaints
5.1 Coroners are committed to providing a service which meets your needs. They welcome feedback, including where the service has performed well. You should direct this to the coroner who dealt with the case.
5.2 If you are dissatisfied with an aspect of the coroner inquiry and want to seek redress, the rest of section 5 will guide you as to where to direct your challenge or complaint.
5.3 You may challenge a coroner's decision or an inquest conclusion. If you wish to do this you should first seek advice from a lawyer with expertise in this area of the law. Bereavement support organisations may be able to help bereaved people in deciding whether a coroner's decision could be challenged in this manner.
5.4 If you decide to proceed, you may make an application to the High Court for judicial review of a coroner's decision or conclusion. This must normally be done within three months of the coroner's decision or conclusion.
5.5 There is a separate power under which the Attorney-General may initiate an application to the High Court for an inquest to be held if a coroner has neglected or refused to hold one, or for another inquest to be held on the grounds that it is necessary or desirable (e.g. because new evidence has come to light).
5.6 Legal aid is available for most public law challenges (including judicial review proceedings), subject to the statutory tests of the client's means and merits of the case. See the Guide (paragraph 21) for more information.
5.7 Information about which solicitors undetake legally-aided work is in the Community Legal Services Directory, which you can find in most reference libraries and Citizens Advice Bureaux, or by visiting Advisor Search.
The Law Society also provides a database of solicitors, which you can access by calling 020 7242 1222 or by visiting Find a solicitor.
5.8 Further information on legal aid is available online at Get legal advice.
5.9 If you are unhappy with a coroner's personal conduct you may complain to the Office for Judicial Complaints (OJC). Examples of possible personal misconduct are using insulting, rascist or sexist language in court, failing to fufil judicial duties or inappropriate behaviour outside the court such as a coroner using his or her judicial title for personal advantage or preferential treatment.
5.10 There is no charge for complaining to the OJC and it can be done online via the OJC website at Judicial complaints. Alternatively, you can download the OJC complaints form and send it to the OJC by fax, post or email. You can also complain by letter or email.
The OJC's contact details are:
Office for the Judicial Complaints
11 Tothill Street
3rd Floor, 3.01-3.03
London SW1H 9LJ
Tel: 020 3334 0145
Fax: 020 3334 0031
Minicom VII: 020 334 0146
(Helpline for the deaf and hard of hearing)
5.11 If you wish to complain about the personal conduct of a deputy coroner or assistant deputy coroner you may write to the coroner whom the deputy or assistant deputy supports.
If you think that the coroner's handling of a complaint about his or her deputy or assistant deputy amounts to personal misconduct of the coroner then you can refer the matter to the OJC.
However, the OJC cannot deal with the actual complaint against the deputy or assistant deputy coroner.
5.12 Further information about complaints about coroners can be found on the OJC website at Judicial complaints.
5.13 If you believe the service you have received falls short of the standards set out in this Charter or wish to complain about the way an inquiry was handled or about the conduct of the coroners' officers, you should first write to the coroner.
You should copy your letter to the local authority which funds the service.
The coroner's office will be able to advise you of the relevant local authority, if you are unsure of this.
5.14 You may also complain direct to the local authority. If you are dissatisfied with the council's response the next step is to complain to the Local Government Ombudsman, at
Make a complaint, or by calling 0800 061 0614 or 0845 602 1983. Alternatively a complaint may be made in writing to:
The Local Government Ombudsman
PO Box 4771
Coventry CV4 0EH
There is no charge to complain about the standard of service from a coroner's office.
5.15 The General Medical Council (GMC) deals with the most serious concerns about doctors and would normally expect concerns about a pathologist to be referred by the coroner. However, if you have a serious concern about a doctor you can complain direct to the GMC, which can take action to remove or restrict a doctor's right to practise it is considers that there has been a serious or persistant breach of its guidance. You can submit a complaint online at
Patient online complaints. For further information, or if you wish to speak to an adviser, please telephone 0161 923 6602.
Section 6 – Monitoring the service standards contained in this Charter
6.1 At the time of publishing this Charter the Ministry of Justice is preparing to set up a Bereavement Organisations Committee. The Committee will have the specific remit of assessing the impact that the Charter is having on coroner services. The assessment will be based on an analysis of complaints and feedback information that the Committee receives and will be reported to Ministers.
Further details will be available on Ministry of Justice when the Committee is convened.
6.2 The Ministry of Justice publishes annual statistics on deaths reported to coroners. These cover deaths reported, post-mortem examinations ordered, and inquests held, and are used to monitor coroners' workloads, throughput of cases, and percentages of post-mortem examinations and inquests.
Details are available at Annual reports.
The Committee will also be able consider such information when assessing the standards of service being provided.
1. "Bereaved family member" means a person who is a parent, child, sibling, spouse, civil partner or partner of the deceased. They also have status of a 'properly interested person' under Rule 20 of the Coroners Rules 1984.
2. "Coroner's office" includes any member of the office of the coroner who is investigating the death. It could be the coroner, deputy coroner, assistant deputy coroner, a coroner's officer, or any other member of staff in the office. It also includes a coroner's officer or other staff member who is based on different premises to the coroner they support.
3. "Inform", or "informed" means the giving of information by leaflet, letter, email, telephone call, via a website or in person.
4. "Inquest" is a fact-finding inquiry to establish who has died, and how, when and where the death occurred. An inquest does not establish any matter of liability or blame.
5. "Next of kin" means the person identified by the coroner or coroner's office to act as the main contact point to receive information.
6. "Pathologist" is a medical professional who specialises in the diagnosis of diesease after death and identifying the causes of death. He or she carries out a post-mortem examination.
7. "Post-mortem examination" is a detailed medical examination of the body that takes place after death and is conducted by a pathologist. It is also known as an autopsy. The purpose of the post-mortem examination is to establish the medical cause of death.
8. "Pre-inquest hearing or review" is a public hearing that the coroner may choose to hold in order to decide matters such as scope and date of the inquest and witnesses and evidence he or she plans to call and use. The coroner may also set out what else he or she needs in order to complete preparations for the inquest.
9. "Properly interested person" is defined in rule 20 of the Coroners Rules 1984 as follows:
- a parent, child, spouse, civil partner, partner and any personal representative of the deceased;
- any beneficiary of a life insurance policy on the deceased;
- any insurer having issued such a policy;
- a representative from a Trade Union to whom the deceased belonged at the time of death (if the death may have been caused by an injury received in the course of the person's employment, or was due to industrial disease);
- anyone whose action or omission may, in the coroner's view, have caused or contributed to the death;
- the Chief Officer of Police (who may only ask witnesses questions through a lawyer);
- any person appointed as an inspector or a representative of an enforcing authority or a person appointed by a government department to attend the inquest; or
- anyone else who the coroner may decide also has a proper interest.
It is the coroner who decides who will be given properly interested person status.
10. "Witness" is someone who, under oath or affirmation at an inquest gives evidence in order to establish who the deceased was, and how, when and where they came by their death.
11. "Working day" means any day, except a designated bank holiday, between Monday and Friday inclusive.