Charles B Greenlaw, Coroner of Calcutta

A coroner is a government or judicial official who is empowered to conduct or order an inquest into the manner or cause of death. The official may also investigate or confirm the identity of an unknown person who has been found dead within the coroner's jurisdiction.

In medieval times, English coroners were Crown officials who held financial powers and conducted some judicial investigations in order to counterbalance the power of sheriffs or bailiffs.

Depending on the jurisdiction, the coroner may adjudge the cause of death personally, or may act as the presiding officer of a special court (a "coroner's jury"). The term coroner derives from the same source as the word crown.

Duties and functions

Responsibilities of the coroner may include overseeing the investigation and certification of deaths related to mass disasters that occur within the coroner's jurisdiction. A coroner's office typically maintains death records of those who have died within the coroner's jurisdiction.

The additional roles that a coroner may oversee in judicial investigations may be subject to the attainment of suitable legal and medical qualifications. The qualifications required of a coroner vary significantly between jurisdictions and are described below under the entry for each jurisdiction. Coroners, medical examiners and forensic pathologists are different professions.[1] They have different roles and responsibilities.[further explanation needed]

Etymology and history

The office of coroner originated in medieval England[2][3][4] and has been adopted in many countries whose legal systems have at some time been subject to English or United Kingdom law. In Middle English, the word "coroner" referred to an officer of the Crown, derived from the French couronne and Latin corona, meaning "crown".[5]

The office of the coroner dates from approximately the 11th century, shortly after the Norman conquest of England in 1066.

The office of coroner was established by lex scripta in Richard I's England. In September 1194, it was decreed by Article 20 of the "Articles of Eyre" to establish the office of custos placitorum coronae (Latin for "keeper of the pleas of the Crown"), from which the word "coroner" is derived.[6][7] This role provided a local county official whose primary duty was to protect the financial interest of the Crown in criminal proceedings. The office of coroner is, "in many instances, a necessary substitute: for if the sheriff is interested in a suit, or if he is of affinity with one of the parties to a suit, the coroner must execute and return the process of the courts of justice."[8] This role was qualified in Chapter 24 of Magna Carta in 1215, which states: "No sheriff, constable, coroner or bailiff shall hold pleas of our Crown." "Keeping the pleas" was an administrative task, while "holding the pleas" was a judicial one that was not assigned to the locally resident coroner but left to judges who traveled around the country holding assize courts. The role of custos rotulorum or keeper of the county records became an independent office, which after 1836 was held by the lord-lieutenant of each county.

The person who found a body from a death thought sudden or unnatural was required to raise the "hue and cry" and to notify the coroner.[4] While coronial manuals written for sheriffs, bailiffs, justices of the peace and coroners were published in the sixteenth and seventeenth centuries, handbooks specifically written for coroners were distributed in England in the eighteenth century.[9]

Coroners were introduced into Wales following its military conquest by Edward I of England in 1282 through the Statute of Rhuddlan in 1284.

Going further back in time, we find that the term comes from antiquity, namely when the deceased was entrusted to the coronator, that is to a necrofor who prepared the corpse according to custom and, among other things, put a small laurel or myrtle wreath (Lat. corona or serta) on his head so that he might be accepted in glory in the afterlife. The use was already of ancient Greece and see e. g. Theophilus Christophorus Harles (Bionis smyrnaei and Moschi syracusani quae supersunt etc. P. 40. Erlangen, 1780), who quotes Euripides, Clement of Alexandria, Chionus of Heraclea and others in this regard; see also James Claude Upshaw Downs: "The origin of official death investigation is traced to at least 44 B.C. with the Greek Physician Antistius's examination of Julius Caesar (Fisher 1993; Gawande 2001). The history of the office of coroner extends well over a millennium and has seen major evolution etc." (Coroner and Medical Examiner in Handbook of Death and Dying ed. by Clifton D. Bryant. V. 1, p. 909. 2003.)

By region


Australian coroners are responsible for investigating and determining the cause of death for those cases reported to them. In all states and territories, a coroner is a magistrate with legal training, and is attached to a local court. Four states – New South Wales, South Australia, Victoria and Western Australia – also have state coroners and specialised coronial courts. In Tasmania, the Chief Magistrate also acts as the state coroner.[10]


In Brazil, the coroners (Médicos-Legistas) are, at first, forensic experts and, consequently, police officers.

In the Department of Federal Police, according to the National Association of Federal Forensic Experts (Associação Nacional dos Peritos Criminais Federais - APCF), "the Federal Forensic Expert is a police officer with technical and scientific knowledge in the service of justice and a professional specialized in finding or providing so-called material evidence through the scientific analysis of traces produced and left in the commission of crimes",[11] what, in case of the coroners (inserted in the aforementioned career), applies in relation to highly complex federal crimes involving corpses that need to be examined by the Forensic Medicine and Dentistry Sector linked to the National Institute of Criminalistics.

Throughout the federative units, the Civil Polices (in Federal District and other 6 States) or Scientific Polices (in all other 20 States) disposes of their own Institutes of Legal Medicine (mainly responsible for confirming the authorship, dynamics and materiality of offenses involving human beings or their respective corpses) and, with the exception of Paraná, the coroners constitute a police career of their own.


According to Statistics Canada,[12]

Death investigation is the responsibility of each individual Canadian province and territory—there is no overarching federal authority. As a result, each province and territory has developed their own system and legislation to fulfill the mandate of investigating deaths that are unexpected, unexplained, or as a result of injuries or drugs. Two different death investigation systems have developed in Canada: the Coroner's system and the Medical Examiner's system. The Coroner's system is used in the majority of provinces and territories. It is a system that is centuries old and originated in Great Britain. It is found throughout the world in countries that were former British colonies, including Canada. The Medical Examiner's system (used in Alberta, Manitoba, Nova Scotia, and Newfoundland and Labrador) is just over one century old and originated in the United States. Although there are some differences between the two systems, the ultimate goal of each is the same—to investigate certain deaths defined in their legislation and establish the identity of the deceased together with the cause of death and the manner of death.

In 21st-century Canada the officer responsible for investigating all unnatural and natural unexpected, unexplained, or unattended deaths goes under the title "coroner" or "medical examiner" depending on location.[12] They do not determine civil or criminal responsibility, but instead make and offer recommendations to improve public safety and prevention of death in similar circumstances.[citation needed]

Coroner or Medical Examiner services are under the jurisdiction of provincial or territorial governments, and in modern Canada generally operate within the public safety and security or justice portfolio. These services are headed by a Chief Coroner (or Chief Medical Examiner) and comprise coroners or medical examiners appointed by the executive council.[citation needed]

The provinces of Alberta,[13] Manitoba,[14] Nova Scotia[15] and Newfoundland and Labrador[16] now have a Medical Examiner system, meaning that all death investigations are conducted by specialist physicians trained in Forensic Pathology, with the assistance of other medical and law enforcement personnel. All other provinces run on a coroner system. In Prince Edward Island,[17] and Ontario,[18] all coroners are, by law, physicians.

In the other provinces and territories with a coroner system, namely British Columbia, Saskatchewan, Quebec, New Brunswick, Northwest Territories, Nunavut, and Yukon, coroners are not necessarily physicians but generally have legal, medical, or investigative backgrounds.[citation needed]

Hong Kong

The Coroner's Court is responsible to inquire into the causes and circumstances of some deaths. The Coroner is a judicial officer who has the power to:

The Coroner makes orders after considering the pathologist's report.


Main article: Iranian Legal Medicine Organization


The Coroners Service is a network of Coroners situated across Ireland, usually covering areas based on Ireland's traditional counties.[19] They are appointed by local authorities as independent experts and must be either qualified doctors or lawyers.[20] Their primary function is to investigate any sudden, unexplained, violent or unnatural death in order to allow a death certificate to be issued. Any death due to unnatural causes will require an inquest to be held.[20]

New Zealand

Two coronial services operate in New Zealand. The older one deals only with deaths before midnight of 30 June 2007 that remain under investigation. The new system operates under the Coroners Act 2006, which:

Sri Lanka

In Sri Lanka, the Ministry of Justice appoints Inquirers into Sudden Deaths under the Code of Criminal Procedure to carry out an inquest into the death of a sudden, unexpected and suspicious nature. Some large cities such as Colombo and Kandy have a City Coroners' Court attached to the main city hospital, with a Coroner and Additional Coroner.

United Kingdom

Parts of this article (those related to the consequences of the Coroners and Justice Act 2009) need to be updated. Please help update this section to reflect recent events or newly available information. (March 2010)

In the United Kingdom a coroner is a specialist judge. Whilst coroners are appointed and paid by local authorities, they are not employees of those local authorities but rather independent judicial office holders who can be removed from office only by the Lord Chief Justice and the Lord Chancellor. The Ministry of Justice, which is headed by the Lord Chancellor and Secretary of State for Justice, is responsible for coronial law and policy. However it has no operational responsibility for the running of coroners' courts.[22]

There are separate coroners services for England and Wales and for Northern Ireland. There are no longer coroners in Scotland. Coroners existed in Scotland between about 1400 and 1800 when they ceased to be used.[23] Now deaths requiring judicial examination are reported to the procurator fiscal and dealt with by fatal accident inquiries conducted by the sheriff for the area.

The coroner's jurisdiction is limited to determining who the deceased was and how, when and where they came by their death. When the death is suspected to have been either sudden with unknown cause, violent, or unnatural, the coroner decides whether to hold a post-mortem examination and, if necessary, an inquest. The majority of deaths are not investigated by the coroner. If the deceased has been under medical care, or has been seen by a doctor within 14 days of death, then the doctor can issue a death certificate. However, if the deceased died without being seen by a doctor, or if the doctor is unwilling to make a determination, the coroner will investigate the cause and manner of death. The coroner will also investigate when a death is deemed violent or unnatural, where the cause is unknown, where a death is the result of poisoning or industrial injury, or if it occurred in police custody or prison.

The coroner's court is a court of law, and accordingly the coroner may summon witnesses. Those found to be lying are guilty of perjury. Additional powers of the coroner may include the power of subpoena and attachment, the power of arrest, the power to administer oaths, and sequester juries of six during inquests.

Any person aware of a dead body lying in the district of a coroner has a duty to report it to the coroner; failure to do so is an offence. This can include bodies brought into England or Wales.[24][25]

The coroner has a team of coroner's officers (previously often ex-police officers, but increasingly from a nursing or other paramedical background) who carry out the investigation on the coroner's behalf. A coroner's investigation may involve a simple review of the circumstances, ordering a post-mortem examination, or they may decide that an inquest is appropriate. When a person dies in the custody of the legal authorities (in police cells, or in prison), an inquest must be held. In England, inquests are usually heard without a jury (unless the coroner wants one). However, a case in which a person has died under the control of central authority must have a jury, as a check on the possible abuse of governmental power.[24][25]

Coroners also have a role in treasure cases. This role arose from the ancient duty of the coroner as a protector of the property of the Crown. It is now contained in the Treasure Act 1996. This jurisdiction is no longer exercised by local coroners, but by specialist "coroners for treasure" appointed by the Chief Coroner.

Inquest conclusions (previously called verdicts)

The coroner's former power to name a suspect in the inquest conclusion and commit them for trial has been abolished.[26] The coroner's conclusion sometimes is persuasive for the police and Crown Prosecution Service, but normally proceedings in the coroner's court are suspended until after the outcome of any criminal case is known. More usually, a coroner's conclusion is also relied upon in civil proceedings and insurance claims. The coroner commonly tells the jury which conclusions are lawfully available in a particular case.

The most common short-form conclusions include:[27]

Alternatively, an inquest may return a narrative conclusion, a brief statement explaining the circumstances how the person came about their death. A coroner giving a narrative conclusion may choose to refer to the other conclusion.[28] A narrative conclusion may also consist of answers to a set of questions posed by the coroner to himself or to the jury (as appropriate).

Lawful killing includes lawful self-defence. There is no material difference between an accidental death conclusion and one of misadventure.[29] Neglect cannot be a conclusion by itself. It must be part of another conclusion. A conclusion of neglect requires that there was a need for relevant care (such as nourishment, medical attention, shelter or warmth) identified, and there was an opportunity to offer or provide that care that was not taken. An open conclusion should only be used as a last resort and is given where the cause of death cannot be identified on the evidence available to the inquest.

Conclusions are arrived at on the balance of probabilities; prior to 2020, conclusions of suicide or unlawful killing were required to be proved to the criminal standard of beyond reasonable doubt.[30]

England and Wales

See also: Inquests in England and Wales

The coroner service in England and Wales is supervised by the Chief Coroner, a judge appointed by the Lord Chief Justice after consulting the Lord Chancellor. The Chief Coroner provides advice, guidance and training to coroners and aims to secure uniformity of practice throughout England and Wales. The post is currently part-time. The present Chief Coroner is Judge Thomas Teague.

England and Wales are divided into coroner districts by the Lord Chancellor, each district consisting of the area or areas of one or more local authorities. The relevant local authority, with the consent of the Chief Coroner and the Lord Chancellor, must appoint a senior coroner for the district. It must also appoint area coroners (in effect deputies to the senior coroner) and assistant coroners, to the number that the Lord Chancellor considers necessary in view of the physical character and population of the district. The cost of the coroner service for the district falls upon the local authority or authorities concerned, and thus ultimately upon the local inhabitants. There are 98 coroners in England and Wales, covering 109 local authority areas.[31]

To become a coroner in England and Wales the applicant must be a qualified solicitor, barrister, or a Fellow of the Chartered Institute of Legal Executives (CILEx) with at least five years' qualified experience.[32] This reflects the role of a coroner: to determine the cause of death of a deceased in cases where the death was sudden, unexpected, occurred abroad, was suspicious in any way, or happened while the person was under the control of central authority (e.g., in police custody). Until 2013 a qualified medical practitioner could be appointed, but that is no longer possible. Any medical coroner still in office will either have been appointed before 2013, or, exceptionally, will hold both medical and legal qualifications.

Formerly, every justice of the High Court was ex officio a coroner for every district in England and Wales. This is no longer so; there are now no ex officio coroners. A senior judge is sometimes appointed ad hoc as a deputy coroner to undertake a high-profile inquest, such as those into the deaths of Diana, Princess of Wales and the victims of the 2005 London bombings.

Northern Ireland

Coronial services in Northern Ireland are broadly similar to those in England and Wales, including dealing with treasure trove cases under the Treasure Act 1996. Northern Ireland has three coroners, who oversee the province as a whole. They are assisted by coroners' liaison officers and a medical officer.[33]

United States

As of 2004, of the 2,342 death investigation offices in the United States, 1,590 were coroners' offices, 82 of which served jurisdictions of more than 250,000 people.[34] Qualifications for coroners are set by individual states and counties in the U.S. and vary widely. In many jurisdictions, little or no training is required, even though a coroner may overrule a forensic pathologist in naming a cause of death. Some coroners are elected with others appointed. Some coroners hold office by virtue of holding another office. For example, in Nebraska, a county's district attorney is also the county's coroner. Similarly, in many counties in Texas, the justice of the peace may be in charge of death investigation. In yet other places, the sheriff may be the lawful coroner.

In different jurisdictions the terms "coroner" and "medical examiner" are defined differently. In some places, stringent rules require that the medical examiner be a forensic pathologist. In others, the medical examiner must be a physician, though not necessarily a pathologist nor further specialized forensic pathologist; physicians with no experience in forensic medicine have become medical examiners.[35] In other jurisdictions, such as Wisconsin, each county sets standards, and in some, the medical examiner does not need any medical or educational qualifications.[36]

Not all U.S. jurisdictions use a coroner system for medicolegal death investigation—some operate with only a medical examiner system, while others operate on a mixed coroner–medical examiner system. In the U.S., the terms "coroner" and "medical examiner" vary widely in meaning by jurisdiction, as do qualifications and duties for these offices.[37] Advocates have promoted the medical examiner model as more accurate given the more stringent qualifications.[38]

Local laws define the deaths a coroner must investigate. The most often legally required investigation is for sudden or unexpected deaths, in addition to deaths where no attending physician was present. Additionally, the law often requires investigations for deaths that are suspicious (as defined by jurisdiction) or violent.[37] In some places in the United States, a coroner has other special powers, such as the ability to arrest the county sheriff.[citation needed]


Duties always include determining the cause, time and manner of death. The coroner/ME typically uses the same investigatory skills of a police detective because the answers are available from the circumstances, scene, and recent medical records. Many American jurisdictions require that any death not certified by an attending physician be referred to the medical examiner for the location where the death occurred. Only a small percentage of deaths require an autopsy to determine the time, cause and manner of death.

In some states, coroners have additional authority. For example:

Notable examples

Artistic depictions




This section possibly contains original research. Relevant discussion may be found on Talk:Coroner. Please improve it by verifying the claims made and adding inline citations. Statements consisting only of original research should be removed. (July 2018) (Learn how and when to remove this message)

Although coroners are often depicted in police dramas as a source of information for detectives, there are a number of fictional coroners who have taken particular focus on television.

See also


  1. ^ "Coroner vs. medical examiner". Visible Proofs. United States National Library of Medicine. Retrieved 1 May 2018.
  2. ^ "coroner". Encyclopædia Britannica, 2009. Accessed 10 August 2009.
  3. ^ Coroner History. Lycoming County, Pennsylvania. Accessed 10 August 2009.
  4. ^ a b Duggan, Kenneth F. (2017). "The Hue and Cry in Thirteenth-Century England". Thirteenth Century England. XVI: 153–172. doi:10.1017/9781787441439.010. ISBN 9781787441439.
  5. ^ "coroner". Merriam Webster. Retrieved 28 May 2013.
  6. ^ "Online Etymology Dictionary: coroner (n.)".
  7. ^ Gross, Charles (1892). "The Early History and Influence of the Office of Coroner". Political Science Quarterly. 7 (4): 656–672. doi:10.2307/2139446. JSTOR 2139446.
  8. ^ James Wilson, Lectures on Law, vol. 2, chapter 7
  9. ^ Trabsky, Marc (2016). "The Coronial Manual and the Bureaucratic Logic of the Coroner's Office". International Journal of Law in Context. 12 (2): 195–209. doi:10.1017/S1744552316000069. S2CID 148552738. Retrieved 2 January 2017.
  10. ^ "Who works at a morgue?". Australian Museum. 27 October 2009. Retrieved 1 August 2017.
  11. ^ felipematos7 (8 April 2019). "O Perito Criminal Federal". APCF (in Brazilian Portuguese). Retrieved 2 May 2024.((cite web)): CS1 maint: numeric names: authors list (link)
  12. ^ a b "Introduction: Coroner Canadian Medical Examiner Database: Annual Report". Government of Canada. 27 November 2015.
  13. ^ "Office of the Chief Medical Examiner". Alberta Justice and Solicitor General. Retrieved 26 May 2013.
  14. ^ "The Role of the Chief Medical Examiner's Office". Manitoba Justice. Archived from the original on 30 March 2014. Retrieved 28 May 2013.
  15. ^ "Nova Scotia Medical Examiner Service". Nova Scotia. Retrieved 28 May 2013.
  16. ^ "Office of the Chief Medical Examiner". Newfoundland – Labrador Department of Justice. Retrieved 28 May 2013.
  17. ^ "Coroner". 16 March 2016.
  18. ^ "Medical".
  19. ^ "Coroner Service". Coroner Service. Archived from the original on 17 September 2016. Retrieved 14 December 2016.
  20. ^ a b "Who are the coroners". Coroner Service. Archived from the original on 17 April 2016. Retrieved 14 December 2016.
  21. ^ "Welcome to the Coronial Services of New Zealand". New Zealand Ministry of Justice. Retrieved 10 October 2010.
  22. ^ "Coroners – Ministry of Justice". Archived from the original on 27 December 2008. Retrieved 3 November 2007.
  23. ^ Houston, R. A. (2014). The Coroners of Northern Britain c. 1300-1700. London, England: Palgrave Pivot. pp. 38–68. ISBN 978-1-137-38107-1.
  24. ^ a b Coroners at; retrieved 6 July 2018
  25. ^ a b General information about the coroner service at; retrieved 6 July 2018
  26. ^ "Criminal Law Act 1977: Section 56",, The National Archives, 1977 c. 45 (s. 56)
  27. ^ "Coroners Inquests". Health and Safety Executive.
  28. ^ R v HM Coroner for the County of West Yorkshire, ex parte Sacker [2004] UKHL 11.
  29. ^ R v Portsmouth Coroner, ex parte Anderson (1987) 1 WLR 1640
  30. ^ R (on the application of Maughan) (Appellant) v Her Majesty’s Senior Coroner for Oxfordshire (Respondent) (2020) UKSC 46
  31. ^ Coroners at; retrieved 5 July 2018
  32. ^ "Coroners" at; reviewed 2 July 2018
  33. ^ Coroner service for Northern Ireland at; retrieved 5 July 2018
  34. ^ J. M. Hickman, K. A. Hughes, K. J. Strom, and J. D. Ropero-Miller, Medical Examiners and Coroners' Offices, (2004). U.S. Department of Justice, Bureau of Justice Statistics Special Report NCJ216756.
  35. ^ Frontline: Post Mortem
  36. ^ Keach, Jenifer (2006). Coroners and Medical Examiners A Comparison of Options Offered by Both Systems in Wisconsin.
  37. ^ a b National Academy of Sciences, Strengthening Forensic Science in the United States: A Path Forward, (2009), pp. 241–253.
  38. ^ Death Investigations: Last Week Tonight with John Oliver (HBO)
  39. ^ Title 15, Chapter 16, Section 8 of Georgia law and Ch. 152 of NC law
  40. ^ Section 30-10-604, Colorado revised statutes
  41. ^ Section 284, New York State Laws of 1915
  42. ^ Helpern, Milton (1977). "Beginnings". Autopsy: the memoirs of Milton Helpern, the world's greatest medical detective. New York: St. Martin's Press. pp. 12–13. ISBN 0-451-08607-4.
  43. ^ "Sheriff-Coroner". California State Association of Counties. 26 May 2015.
  44. ^ Allan, Blaine. "Wojeck". CBC Television Series, 1952–1982. Queen's Film and Media. Archived from the original on 15 March 2010.

Further reading

Coroners by country