Coroners – Post-Mortem

The Coroners (Investigations) Regulations 2013 came into force on 25th July 2013.

“These Regulations regulate the practice and procedure relating to investigations into deaths carried out under Part 1 of the Coroners and Justice Act 2009 (“the 2009 Act”).

Part 1 of the 2009 Act introduced a new regime for death investigations, which replaces the Coroners Act 1988 and the Coroners Rules 1984. Under the 2009 Act a coroner must conduct an investigation into violent or unnatural deaths, deaths where the cause is unknown and deaths which occur in custody or otherwise in state detention. In certain cases this investigation will include the coroner holding an inquest”.

In respect of a coroner’s post-mortem, Regulation 13 states:

(1) Where a coroner has requested a suitable practitioner to make a post-mortem examination, the coroner must notify the persons or bodies listed in paragraph (3) of the date, time and place at which that post-mortem examination is to be made.

(2) A coroner need not give such notification, where it is impracticable or where to do so would cause the post-mortem examination to be unreasonably delayed.

(3) The persons to be notified are—

(a) the next of kin or the personal representative of the deceased or any other interested person who has notified the coroner in advance of his or her desire to be represented at the post-mortem examination;

(b) the deceased’s regular medical practitioner, if he or she has notified the coroner of his or her desire to be represented at the post-mortem examination;

(c) if the deceased died in hospital, that hospital;

(d) if the death of the deceased may have been caused by an accident or disease which must be reported to an enforcing authority, to that enforcing authority or the appropriate inspector or representative of that authority;

(e) a Government department which has notified the coroner of its desire to be represented at the examination; and

(f) if the chief officer of police has notified the coroner of his or her desire to be represented at the examination, the chief officer of police.

(4) Any of the persons or bodies listed in paragraph (3) are entitled to be represented at a post-mortem examination by a medical practitioner, or if they are a medical practitioner, may attend themselves.

(5) The following persons may attend a post-mortem examination—

(a) A representative of the chief officer of police from the police force of which he or she is chief officer; and

(b) any other person including a trainee doctor, medical student or other medical practitioner but only with the consent of the coroner.

It may prove useful to know that there are some alternatives to traditional post-mortem. One alternative is Magnetic Resonance Imaging (MRI). This is a scanning mechanism which can in some circumstances determine cause of death, but is only available in some districts. It can also be very expensive.

There are also other less invasive procedures which can determine the cause of death. It would be wise to discuss the options with a coroner or an officer for the coroner. Some religions strictly forbid post-mortem. Both Islam and Judaism teach that bodies should be buried as soon as possible after death, and must not be defiled. The Roman Catholic Church and the Church of England do not have objections to post-mortem. It is my understanding that coroners will seek to respect the views of the objectors on religious grounds, but can overrule requests if they believe the cause of death could not be ascertained through an MRI scan or other less invasive procedure.

Many people removed from religion complain that post-mortem is carried out far too frequently and that invasive procedures are adopted when they are not always absolutely necessary. Some academics support this view, and though I am not an academic, so do I.

I have located details of court cases in Australia where judges have overruled decisions made by coroners to order post-mortems. Though decisions were made in Australia, if relied on to bring the same legal challenge in the UK, the Courts might consider these cases are “persuasive” or even “compelling” and arrive at the same conclusion. I reiterate that I am not a lawyer, but I am happy to provide case details to other lay folk.

The role of a Coroner

Information about the role of a coroner can be located in the guide to Coroners and Inquests that is produced by the Coroners Unit at the Ministry of Justice.  Note that the legal right of the next of kin or other certain persons to be present at a post-mortem has been done away with. That legal right was once granted in Rule 7 Section 2(a) of the Coroners Rules 1984, but those Rules have been replaced by The Coroners (Investigations) Regulations 2013. Note above Regulation 13(4) “Any of the persons or bodies listed in paragraph (3) are entitled to be represented at a post-mortem examination by a medical practitioner, or if they are a medical practitioner, may attend themselves”.

The Coroners Officers Association (COA) constitution states: Coroners’ Officers and Coroners’ Staff are defined as persons responsible to one of Her Majesty’s Coroners who have a role in the procedures for dealing with sudden, unexpected or unnatural deaths.

The objects of the Association are to:

• advance the expertise of Coroners’ Officers and Coroners’ Staff

• formulate and promote continuous professional development for Coroners’ Officers and Coroners’ Staff

• pursue national standards of working practices for all Coroners’ Officers and Coroners’ Staff

• pursue national standards of pay, terms and conditions for all Coroners’ Officers and Coroners’ Staff (other than serving police officers)

• act as a negotiating and advisory body when required

• act as liaison on matters concerning Coroners’ Officers and Coroners’ Staff with any relevant government department or other organisation or association

Despite the COA’s constitution I have received many complaints about police officers acting for a coroner that fail to give sound guidance to newly bereaved people. Guidance might include what the legal position is once a coroner releases a body from his custody. NOTE Training is not a mandatory requirement. It appears to remain a lottery to whether the bereaved will be dealing with a trained or an untrained officer acting for a coroner.

When a coroner releases a body from his custody!

Contrary to how many coroner’s and their staff behave when a coroner releases a body from his custody a coroner cannot dictate whether a relative can see or touch the body.  Neither is a coroner able to dictate who the body must be released to.  It is the legal right of the next of kin to take lawful possession of the body, unless there is a Will. If a Will exists the rights turn to the executor.  If no executor has been named and a next of kin obtains a ‘letter of administration’ it is this person (the administrator) legal right to take lawful possession of the body for the purpose of “disposal” (an insensitive legal term) by way of burial, cremation or “any other means”.  The term “any other means” was in the 1988 Coroners Act but I cannot now find any mention of that in any current law re coroners, including The Coroners (Investigations) Regulations 2013. The term has remained in registration law for births and deaths, i.e. Section 12 of the Births & Deaths Registration Act 1926 and Section 41 of the Births & Deaths Registration Act 1953. There is no clear legal definition of “disposal”. For example do the words “any other means” cover everything from the various ways in which bodies can be destroyed right through to various methods of preservation? Bodies would be regarded as being destroyed through cremulation, resomation and promession.  Forms of preservation might include donating bodies for medical and scientific purposes and a process known as plastination which could be used for artistic, religious or other purposes. The only legal duty is that the body is not neglected or abandoned.  In other words something lawful must be done with the body.

Note The Office of Judicial Complaints can look at a complaint about a coroner’s personal conduct. It cannot look at any complaint that relates to decisions that a coroner makes or has made which are governed by The Coroners (Investigations) Regulations 2013. Here are details about How to Complain.

The current guide to Coroners and Inquests does not discuss the collection and storage of bodies of people that have died, so I feel that it is necessary to discuss this here.

Councils’ (local authorities), coroners and funeral companies.

A council (local authority) makes sure the coroner has appropriate accommodation to hold Inquest hearings and appropriate office accommodation for him, his deputy and their admin team. Coroners staff, be they officers, clerks, admin staff or ushers are employed by the council which pays their wages – usually the local authority, but it can be the police authority. A council also provides IT support, and funds the coroner’s and deputies’ salaries (fixed payments), but they are not employed by the council. No coronial office holder is employed – not even by the Crown. They hold office and the local authority have to pay their salary and expenses. Deputy coroners tend to be fee paid – that is they have a fee for each day they cover – but some do receive a salary.

Councils make contracts with funeral companies for undertakers to collect on behalf of coroners wanting to investigate a death, the bodies of those that have died suddenly and unexpectedly. These contracts are commonly known in the funeral industry as a ‘body removal service contract’. I am reliably informed that these contracts are often tendered out for little monetary value, though councils must abide by The Public Contracts Regulations 2006.

The Regulations does not make specific reference to councils making contracts with funeral companies, but Section 39 of the Regulations states that:

(1) A contracting authority may stipulate conditions relating to the performance of a public contract, provided that those conditions are compatible with Community law (European law) and are indicated in—

(a) the contract notice and the contract documents; or

(b) the contract documents.

(2) The conditions referred to in paragraph (1) may, in particular, include social and environmental considerations.

The word “social” appears to imply that a council must incorporate terms and conditions into contracts that are socially acceptable.

Many people might question whether it is socially acceptable for an undertaker collecting a body on behalf of a coroner to solicit for funeral orders. Indeed Code 9 of the National Association of Funeral Directors (NAFD) Codes of Practice stipulates that a member is: to refrain from soliciting funeral orders, or offering, or giving any reward for recommendation to persons or organisations such as health service establishments, nursing homes or coroners’ offices, etc.

I know of one council that does not forbid an undertaker under contract to leave a business card when collecting a body on behalf of a coroner from a domestic environment. Given the low monetary value paid to funeral companies under contract, I am confident that there will be people working in other council’s that think soliciting this way is “socially” acceptable. Acceptance of this conduct also appears to contradict the NAFD’s Codes of Practice and may lead many people to consider that accepting a low value contract in hope of gaining funeral orders is in effect “offering” a council some kind of a “reward”.

Despite my efforts to prevent, least limit, the risk of undertakers soliciting business from acutely vulnerable individuals in such circumstances, the Chief Coroner Peter Thornton QC has shown no interest to call for a change in practice.


The ‘contract’ is between a council and the funeral company. When a coroner has released a body from his/her custody the person taking lawful possession of the body is not compelled, or under any legal obligation to use that same funeral company to continue with any funeral arrangements that they may wish to make.  It matters not whether a funeral company under contract has a mass body refrigeration facility that is or is not attached to its offices, or some other kind of refrigeration facility that a coroner and council considers to be a mortuary facility.  Once the coroner releases a body it remains the legal right of the person taking lawful possession (which is not forced to be an undertaker) to collect the body in a private vehicle, or hire a different funeral company that is not contracted to a council to do so on their behalf.