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HM Coroner Service


About the Coroner Service

About the Coroner

A coroner is an independent judicial office holder, appointed by a local council.

Coroners usually have a legal background but will also be familiar with medical terminology.

Coroners investigate deaths that have been reported to them if it appears that:

  • the death was violent or unnatural
  • the cause of death is unknown
  • the person died in prison, police custody, or another type of state detention.

In these cases coroners must investigate to find out, for the benefit of bereaved people and for official records, who has died and how, when, and where they died.

More information on what to expect is at: www.gov.uk/after-a-death/when-a-death-is-reported-to-a-coroner


If it was not possible to find out the cause of death from the post-mortem examination, or the death is found to be unnatural, the coroner has to hold an inquest.

An inquest is a public court hearing held by the coroner in order to establish who died and how, when and where the death occurred.

The inquest will be held as soon as possible and normally within 6 months of the death if at all possible.

If the death occurred in prison or custody, or if it resulted from an accident at work, there will usually be a jury at the inquest.

The coroner (or jury) comes to a conclusion at the end of an inquest:

  • legal ‘determination’ stating who died, and where, when and how they died
  • ‘findings’ to allow the cause of death to be registered.

When recording the cause the coroner or jury may use one of the following terms:

  • accident or misadventure
  • alcohol/drug related
  • industrial disease
  • lawful killing
  • unlawful killing
  • natural cause
  • open
  • road traffic collision
  • stillbirth
  • suicide

The coroner or jury may also make a brief ‘narrative’ conclusion setting out the facts surrounding the death in more detail and explaining the reasons for the decision.


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Coventry Guidance  

Coventry Coroner

Contact us:

Telephone: 024 76 97 55 09

New Email: coroner@coventry.gov.uk  (NOT coroner@coventry.GCSX.gov.uk)

Rugby Guidance  

HM Coroner for Warwickshire: Sean McGovern

Warwickshire Justice Centre
Newbold Terrace
Leamington Spa
CV32 4EL

Tel: 01926 684228

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