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A coroner is a government official who

• Investigates human deaths
• Determines cause of death
• Issues death certificates
• Maintains death records
• Responds to deaths in mass disasters
• Identifies unknown dead
• Other functions depending on local laws

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 office of coroner originated in medieval England^[1][2] and has been adopted in many countries whose legal systems have at some time been subject to English or United Kingdom law. 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 under the entry for each jurisdiction.

Canada[link]

This section appears to contradict itself. Please see the talk page for more information. (October 2011)

In Canada, two systems exist in investigating all unnatural and natural unexpected, unexplained, or unattended deaths: coroner or medical examiner.^[3] While the name differs, they act in similar capacities as 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.

Coroner services in Canada are under the jurisdiction of Provincial or Territorial government, within the public safety and security or justice portfolio depending on location. Coroner service is headed by a Chief Coroner (or Chief Medical Examiner) and is supported by a team of coroners or medical examiners are appointed by the executive council.

In the provinces of Alberta, Manitoba, Ontario, Nova Scotia, Newfoundland and Labrador, and Prince Edward Island, all coroners are, by law, physicians.

In all other provinces and territories, 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.

England and Wales[link]

Parts of this section (those related to the consequences of the Coroners and Justice Act 2009) are outdated. Please update this section to reflect recent events or newly available information. Please see the talk page for more information. (March 2010)

In England and Wales a coroner is an independent judicial office holder, appointed and paid for by the relevant local authority. The Ministry of Justice, which is headed by the Lord Chancellor and Secretary of State for Justice has the responsibility for the coronial law and policy only, and no operational responsibility.^[4]

History[link]

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

The office of coroner was formally established in England by Article 20 of the "Articles of Eyre" in September 1194 to "keep the pleas of the Crown" (Latin, custos placitorum coronae) from which the word "coroner" is derived.^[5] 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."^[6] 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.

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

Qualification[link]

To become a coroner in England and Wales the applicant must have a degree in a medical or legal field, e.g., criminology or bio-medical sciences. Coroners must have had a previous career, in the UK, as a lawyer (solicitor/barrister) or physician of at least five years standing. 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).

Aside from the usual coroners, certain persons are ex officio coroners in limited circumstances—for example the Lord Chancellor has been historically allowed to certify the death of someone killed in rebellion.

Inquest[link]

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 and, if necessary, an inquest.

Verdict[link]

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

The most common verdicts include:^[7]

• Death by natural causes
• Death by misadventure
• Accidental death
• Lawful killing
• Suicide
• Unlawful killing
• Occupational disease
• Drug dependence
• Non-dependent drug abuse
• Attempted abortion
• Self-induced abortion
• Disaster (but only if it has been the subject of a public enquiry)
• Still birth
• Self-neglect
• Lack of care/neglect
• An open verdict
• A narrative verdict

Notes[link]

Lawful killing includes lawful self-defence. There is no material difference between an accidental death verdict and one of misadventure.^[8]

The verdicts of suicide and death by natural causes require proving beyond reasonable doubt. Other verdicts are arrived at on the balance of probabilities.

A verdict 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. Neglect can be ruled an aggravating factor in other verdicts as well as a freestanding verdict.^[9]

An open verdict is given where the cause of death cannot be identified on the evidence available to the inquest.

A coroner giving a narrative verdict may choose to refer to the other verdicts.^[10] A narrative verdict may also consist of answers to a set of questions posed by the Coroner to himself or to the jury (as appropriate).

Jurisdiction[link]

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. The coroner has a team of Coroner's Officers (previously often ex-police officers, but increasingly so from a nursing or other paramedical background) who carry out the investigation on the coroner's behalf. On the basis of the investigation, the coroner decides whether 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.

The coroner's court is a court of law, and accordingly the coroner may summon witnesses, and people found 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.

Coroners also have a role in treasure trove 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.

Hong Kong[link]

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

• Grant:
  • Burial orders
  • Cremation orders
  • Waivers of autopsy
  • Autopsy orders
  • Exhumation orders
  • Orders to remove dead bodies outside Hong Kong
• Order police investigations of death
• Order inquests
• Approve removal and use of body parts of the dead body
• Issue certificates of fact of death

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

New Zealand[link]

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:

• Established the office of the chief coroner to provide leadership and coordination
• Moved to a smaller number of mostly full-time legally qualified coroners
• Ensured families are notified of significant steps in the coronial process
• Introduced a specific regime for attention and release of body parts and body samples
• Enhanced inquiry and inquest processes^[11]

Northern Ireland[link]

Coronial services in Northern Ireland are broadly similar to those in England and Wales, including dealing with Treasure Trove under the Treasure Act 1996.

Scotland[link]

In Scotland, deaths requiring judicial examination are dealt with by Fatal Accident Inquiries.

Japan[link]

In Japan, the coroner's office assists with investigations. Members of the coroner's office are police detectives with field experience. Investigators typically hold the rank of captain and have studied forensic medicine and investigation techniques at the National Police Academy.

United States[link]

As of 2004^[update], of the 2,342 death investigation offices in the United States, 1,590 are coroners offices. Of those, only 82 serve jurisdictions of more than 250,000 people.^[12] 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. A coroner may be elected or appointed. Some coroners hold office by virtue of holding another office: in Nebraska, the county district attorney is the coroner; in many counties in Texas, the Justice of the Peace may be in charge of death investigation; in other places, the sheriff is the coroner.

In North Carolina, many counties ceased having coroners when the state judicial system was overhauled in the late 1960s. Medical examiners were appointed with a requirement to be a licensed physician, often a pathologist or forensic pathologist. Like the office of sheriff, no formal training or education is required for NC coroners, but most have historically been morticians from local funeral homes. Coroners are still officials in at least ten of the state's 100 counties. Coroners are charged by law to investigate cause and manner of any death caused by default of another person (homicide) and may convene a coroner's inquest with a jury of six jurors taken from the county jury pool. Coroners may arrest persons suspected of homicide and can charge other lesser crimes discovered during the course of any such investigation or inquest. They can hold persons in contempt of court for failing to cooperate or comply with an inquest and may issue arrest or material witness warrants, in addition to the setting of bails. Coroners also are required to act as sheriff, should a vacancy in the office occur. They are required to submit a report to the medical examiner and district attorney for cases they investigate.

Because of the differences between jurisdictions, the terms "coroner" and "medical examiner" are defined differently from place to place. 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 forensic pathologist or even a pathologist. General practitioners, obstetricians, and other types of physicians with no experience in forensic medicine have become medical examiners.^[13] In others, such as Wisconsin, each county sets standards, and in some, the medical examiner does not need to meet any medical or educational qualifications of any type.^[14]

Not all U.S. jurisdictions use a coroner system for medicolegal death investigation—some are on a medical examiner system, others are 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.^[15]

Local laws define the deaths a coroner must investigate, but most often include those that are sudden, unexpected, and have no attending physician—and deaths that are suspicious or violent.^[15] In some places in the United States, a coroner has other special powers, such as the ability to arrest the county sheriff. In the United Kingdom, Australia, and other countries, coroners often make recommendations for safety practices that may prevent deaths.

Duties[link]

Duties always include determining the cause, time, and manner of death. This uses the same investigatory skills of a police detective in most cases, because the answers are available from the circumstances, scene, and recent medical records. In many American jurisdictions, any death not certified by the person's own physician must be referred to the medical examiner. If an individual dies outside of his/her state of residence, the coroner of the state in which the death took place issues the death certificate. Only a small percentage of deaths require an autopsy to determine the time, cause and manner of death.

In some states, additional functions are handled by the coroner. For example, in Louisiana, coroners are involved in the determination of mental illness of living persons. In Georgia, the coroner has the same powers as a county sheriff to execute arrest warrants and serve process, and in certain situations where there is no sheriff (described in Title 15, Chapter 16, Section 8 of Georgia law), s/he officially acts as sheriff for the county. In Kentucky, section 72.415 of the Kentucky Revised Statutes gives coroners and their deputies the full power and authority of peace officers. This includes the power of arrest and the authority to carry firearms. In New York City, the office of coroner was actually abolished in 1915,^[16] since before that time, having medical knowledge was not actually a requirement, leading to much abuse of position.^[17]

Notable coroners[link]

• Larry Campbell
• John C. Fleming
• J. Howell Flournoy
• Alexander Fulton
• Morton Shulman
• Graham Hetrick
• Charles Norris
• Thomas Noguchi

Artistic depictions[link]

Film[link]

• In the song "Ding-Dong! The Witch Is Dead," from the classic 1939 film The Wizard of Oz, the Coroner of Munchkinland confirms the death of the Wicked Witch of the East.

Literature[link]

(The following entries are organized by author's last name)

• Patricia Cornwell is a crime novelist well known for her creation of Dr. Kay Scarpetta, a fictional medical examiner based on the Commonwealth of Virginia's former Chief Medical Examiner, Dr. Marcella Fierro.^[18]
• Novelist Bernard Knight, a former Home Office pathologist and a professor of forensic pathology at the University of Wales College of Medicine, is well known for his Crowner John Mysteries series set in 12th century Devon, England. ("Crowner" is an archaic word for "coroner" and is based on the origins of the word. See the History section above.)

Television[link]

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. (The following entries are alphabetized by program title.)

• Autopsy is a sub-series of HBO's America Undercover documentary series. Forensic pathologist Dr. Michael Baden is the primary analyst, and has been involved personally in many of the cases that are reviewed.
• The coroner is a significant character on CSI: Crime Scene Investigation, CSI: Miami, and CSI: NY.
• The lead character in the television series, Crossing Jordan, is a medical examiner.
• The television series Da Vinci's Inquest has a coroner as its title character.
• Dr. G: Medical Examiner is a reality television show shown on the Discovery Fit & Health Channel that shows dramatic reenactments of autopsies performed by real-life medical examiner, Dr. Jan Garavaglia. Episodes also include interviews with Dr. Garavaglia, family members, and others connected with the cases Dr. Garavaglia has worked on in Florida and Texas.
• Dr. Donald "Ducky" Mallard, portrayed by actor David McCallum, is a fictional medical examiner on the American television crime drama, NCIS.
• Sasha Alexander plays the title character of Dr. Maura Isles, MD on the TNT series "Rizzoli & Isles", the Massachusetts Chief Medical Examiner.
• The television series, Quincy, M.E. (and its Canadian ancestor, Wojeck), has a coroner as its title character.
• The television series, Wojeck (the Canadian ancestor of Quincy, M.E.), has a coroner as its title character, inspired by the coroner Dr. Morton Shulman.^[19]
• Body of Proof, starring Dana Delany as Dr. Megan Hunt on the ABC Network is about a medical examiner in Philadelphia, Pennsylvania.

See also[link]

• Coroner's jury
• Forensic pathology
• Medical examiner

References[link]

External links[link]

• Dr. G Medical Examiner: Working With The Dead
• History of the Medieval English Coroner System by Prof. Bernard Knight

Official websites[link]

• Australia, New South Wales - Homepage of the New South Wales,Australian (NSW) Coroners Court
• Australia, Queensland - Queensland Courts, Coroners Court
• Australia, Western Australia - Homepage of West Australian (WA) Coroners Court
• England and Wales - Ministry of Justice, Coroners
• Hong Kong Judiciary - Court Services and Facilities
• New Zealand - Coronial Services of New Zealand
• Northern Ireland - Coroners Service for Northern Ireland