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Part 1Coroners etc

Chapter 1Investigations into deaths

Duty to investigate

1Duty to investigate certain deaths

(1)A senior coroner who is made aware that the body of a deceased person is within that coroner’s area must as soon as practicable conduct an investigation into the person’s death if subsection (2) applies.

(2)This subsection applies if the coroner has reason to suspect that—

(a)the deceased died a violent or unnatural death,

(b)the cause of death is unknown, or

(c)the deceased died while in custody or otherwise in state detention.

(3)Subsection (1) is subject to sections 2 to 4.

(4)A senior coroner who has reason to believe that—

(a)a death has occurred in or near the coroner’s area,

(b)the circumstances of the death are such that there should be an investigation into it, and

(c)the duty to conduct an investigation into the death under subsection (1) does not arise because of the destruction, loss or absence of the body,

may report the matter to the Chief Coroner.

(5)On receiving a report under subsection (4) the Chief Coroner may direct a senior coroner (who does not have to be the one who made the report) to conduct an investigation into the death.

(6)The coroner to whom a direction is given under subsection (5) must conduct an investigation into the death as soon as practicable.

This is subject to section 3.

(7)A senior coroner may make whatever enquiries seem necessary in order to decide—

(a)whether the duty under subsection (1) arises;

(b)whether the power under subsection (4) arises.

(8)This Chapter is subject to Schedule 10.

Investigation by other coroner

2Request for other coroner to conduct investigation

(1)A senior coroner (coroner A) who is under a duty under section 1(1) to conduct an investigation into a person’s death may request a senior coroner for another area (coroner B) to conduct the investigation.

(2)If coroner B agrees to conduct the investigation, that coroner (and not coroner A) must conduct the investigation, and must do so as soon as practicable.

(3)Subsection (2) does not apply if a direction concerning the investigation is given under section 3 before coroner B agrees to conduct the investigation.

(4)Subsection (2) is subject to—

(a)any direction concerning the investigation that is given under section 3 after the agreement, and

(b)section 4.

(5)A senior coroner must give to the Chief Coroner notice in writing of any request made by him or her under subsection (1), stating whether or not the other coroner agreed to it.

3Direction for other coroner to conduct investigation

(1)The Chief Coroner may direct a senior coroner (coroner B) to conduct an investigation under this Part into a person’s death even though, apart from the direction, a different senior coroner (coroner A) would be under a duty to conduct it.

(2)Where a direction is given under this section, coroner B (and not coroner A) must conduct the investigation, and must do so as soon as practicable.

(3)Subsection (2) is subject to—

(a)any subsequent direction concerning the investigation that is given under this section, and

(b)section 4.

(4)The Chief Coroner must give notice in writing of a direction under this section to coroner A.

(5)A reference in this section to conducting an investigation, in the case of an investigation that has already begun, is to be read as a reference to continuing to conduct the investigation.

Discontinuance of investigation

4Discontinuance where cause of death revealed by post-mortem examination

(1)A senior coroner who is responsible for conducting an investigation under this Part into a person’s death must discontinue the investigation if—

(a)an examination under section 14 reveals the cause of death before the coroner has begun holding an inquest into the death, and

(b)the coroner thinks that it is not necessary to continue the investigation.

(2)Subsection (1) does not apply if the coroner has reason to suspect that the deceased—

(a)died a violent or unnatural death, or

(b)died while in custody or otherwise in state detention.

(3)Where a senior coroner discontinues an investigation into a death under this section—

(a)the coroner may not hold an inquest into the death;

(b)no determination or finding under section 10(1) may be made in respect of the death.

This subsection does not prevent a fresh investigation under this Part from being conducted into the death.

(4)A senior coroner who discontinues an investigation into a death under this section must, if requested to do so in writing by an interested person, give to that person as soon as practicable a written explanation as to why the investigation was discontinued.

Purpose of investigation

5Matters to be ascertained

(1)The purpose of an investigation under this Part into a person’s death is to ascertain—

(a)who the deceased was;

(b)how, when and where the deceased came by his or her death;

(c)the particulars (if any) required by the 1953 Act to be registered concerning the death.

(2)Where necessary in order to avoid a breach of any Convention rights (within the meaning of the Human Rights Act 1998 (c. 42)), the purpose mentioned in subsection (1)(b) is to be read as including the purpose of ascertaining in what circumstances the deceased came by his or her death.

(3)Neither the senior coroner conducting an investigation under this Part into a person’s death nor the jury (if there is one) may express any opinion on any matter other than—

(a)the questions mentioned in subsection (1)(a) and (b) (read with subsection (2) where applicable);

(b)the particulars mentioned in subsection (1)(c).

This is subject to paragraph 7 of Schedule 5.

Inquests

6Duty to hold inquest

A senior coroner who conducts an investigation under this Part into a person’s death must (as part of the investigation) hold an inquest into the death.

This is subject to section 4(3)(a).

7Whether jury required

(1)An inquest into a death must be held without a jury unless subsection (2) or (3) applies.

(2)An inquest into a death must be held with a jury if the senior coroner has reason to suspect—

(a)that the deceased died while in custody or otherwise in state detention, and that either—

(i)the death was a violent or unnatural one, or

(ii)the cause of death is unknown,

(b)that the death resulted from an act or omission of—

(i)a police officer, or

(ii)a member of a service police force,

in the purported execution of the officer’s or member’s duty as such, or

(c)that the death was caused by a notifiable accident, poisoning or disease.

(3)An inquest into a death may be held with a jury if the senior coroner thinks that there is sufficient reason for doing so.

(4)For the purposes of subsection (2)(c) an accident, poisoning or disease is “notifiable” if notice of it is required under any Act to be given—

(a)to a government department,

(b)to an inspector or other officer of a government department, or

(c)to an inspector appointed under section 19 of the Health and Safety at Work etc. Act 1974 (c. 37).

8Assembling a jury

(1)The jury at an inquest (where there is a jury) is to consist of seven, eight, nine, ten or eleven persons.

(2)For the purpose of summoning a jury, a senior coroner may summon persons (whether within or without the coroner area for which that coroner is appointed) to attend at the time and place stated in the summons.

(3)Once assembled, the members of a jury are to be sworn by or before the coroner to inquire into the death of the deceased and to give a true determination according to the evidence.

(4)Only a person who is qualified to serve as a juror in the Crown Court, the High Court and the county courts, under section 1 of the Juries Act 1974 (c. 23), is qualified to serve as a juror at an inquest.

(5)The senior coroner may put to a person summoned under this section any questions that appear necessary to establish whether or not the person is qualified to serve as a juror at an inquest.

9Determinations and findings by jury

(1)Subject to subsection (2), a determination or finding that a jury is required to make under section 10(1) must be unanimous.

(2)A determination or finding need not be unanimous if—

(a)only one or two of the jury do not agree on it, and

(b)the jury has deliberated for a period of time that the senior coroner thinks reasonable in view of the nature and complexity of the case.

Before accepting a determination or finding not agreed on by all the members of the jury, the coroner must require one of them to announce publicly how many agreed and how many did not.

(3)If the members of the jury, or the number of members required by subsection (2)(a), do not agree on a determination or finding, the coroner may discharge the jury and another one may be summoned in its place.

Outcome of investigation

10Determinations and findings to be made

(1)After hearing the evidence at an inquest into a death, the senior coroner (if there is no jury) or the jury (if there is one) must—

(a)make a determination as to the questions mentioned in section 5(1)(a) and (b) (read with section 5(2) where applicable), and

(b)if particulars are required by the 1953 Act to be registered concerning the death, make a finding as to those particulars.

(2)A determination under subsection (1)(a) may not be framed in such a way as to appear to determine any question of—

(a)criminal liability on the part of a named person, or

(b)civil liability.

(3)In subsection (2) “criminal liability” includes liability in respect of a service offence.

Suspension

11Duty or power to suspend or resume investigations

Schedule 1 makes provision about suspension and resumption of investigations.

Death of service personnel abroad

12Investigation in Scotland

(1)This section applies to the death outside the United Kingdom of a person within subsection (2) or (3).

(2)A person is within this subsection if at the time of the death the person was subject to service law by virtue of section 367 of the Armed Forces Act 2006 (c. 52) and was engaged in—

(a)active service,

(b)activities carried on in preparation for, or directly in support of, active service, or

(c)training carried out in order to improve or maintain the effectiveness of those engaged in active service.

(3)A person is within this subsection if at the time of the death the person was not subject to service law but—

(a)by virtue of paragraph 7 of Schedule 15 to the Armed Forces Act 2006 was a civilian subject to service discipline, and

(b)was accompanying persons subject to service law who were engaged in active service.

(4)If—

(a)the person’s body is within Scotland or is expected to be brought to the United Kingdom, and

(b)the Secretary of State thinks that it may be appropriate for the circumstances of the death to be investigated under the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 (c. 14),

the Secretary of State may notify the Lord Advocate accordingly.

(5)If—

(a)the person’s body is within England and Wales, and

(b)the Chief Coroner thinks that it may be appropriate for the circumstances of the death to be investigated under that Act,

the Chief Coroner may notify the Lord Advocate accordingly.

13Investigation in England and Wales despite body being brought to Scotland

(1)The Chief Coroner may direct a senior coroner to conduct an investigation into a person’s death if—

(a)the deceased is a person within subsection (2) or (3) of section 12,

(b)the Lord Advocate has been notified under subsection (4) or (5) of that section in relation to the death,

(c)the body of the deceased has been brought to Scotland,

(d)no inquiry into the circumstances of the death under the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 (c. 14) has been held (or any such inquiry that has been started has not been concluded),

(e)the Lord Advocate notifies the Chief Coroner that, in the Lord Advocate’s view, it may be appropriate for an investigation under this Part into the death to be conducted, and

(f)the Chief Coroner has reason to suspect that—

(i)the deceased died a violent or unnatural death,

(ii)the cause of death is unknown, or

(iii)the deceased died while in custody or otherwise in state detention.

(2)The coroner to whom a direction is given under subsection (1) must conduct an investigation into the death as soon as practicable.

This is subject to section 3.

Ancillary powers of coroners in relation to deaths

14Post-mortem examinations

(1)A senior coroner may request a suitable practitioner to make a post-mortem examination of a body if—

(a)the coroner is responsible for conducting an investigation under this Part into the death of the person in question, or

(b)a post-mortem examination is necessary to enable the coroner to decide whether the death is one into which the coroner has a duty under section 1(1) to conduct an investigation.

(2)A request under subsection (1) may specify the kind of examination to be made.

(3)For the purposes of subsection (1) a person is a suitable practitioner if he or she—

(a)is a registered medical practitioner, or

(b)in a case where a particular kind of examination is requested, a practitioner of a description designated by the Chief Coroner as suitable to make examinations of that kind.

(4)Where a person informs the senior coroner that, in the informant’s opinion, death was caused wholly or partly by the improper or negligent treatment of a registered medical practitioner or other person, that practitioner or other person—

(a)must not make, or assist at, an examination under this section of the body, but

(b)is entitled to be represented at such an examination.

This subsection has no effect as regards a post-mortem examination already made.

(5)A person who makes a post-mortem examination under this section must as soon as practicable report the result of the examination to the senior coroner in whatever form the coroner requires.

15Power to remove body

(1)A senior coroner who—

(a)is responsible for conducting an investigation under this Part into a person’s death, or

(b)needs to request a post-mortem examination under section 14 in order to decide whether the death is one into which the coroner has a duty under section 1(1) to conduct an investigation,

may order the body to be removed to any suitable place.

(2)That place may be within the coroner’s area or elsewhere.

(3)The senior coroner may not order the removal of a body under this section to a place provided by a person who has not consented to its being removed there.

This does not apply to a place within the coroner’s area that is provided by a district council, a county council, a county borough council, a London borough council or the Common Council.