H M Coroner, London Inner South

1 Tennis Street, SE1 1YD

Information for just bereaved parents

A guide to
the death investigation process

April 2018

Senior Coroner Andrew Harris

Coroner’s Officer Manager Mr David Leese
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1. Introduction

Losing a child unexpectedly is a uniquely shocking experience. The death

brings unimaginable shock, grief, disbelief, anger and other emotions. It also
inevitably involves a number of organizations and professionals and legal
processes, which will almost certainly be unfamiliar and may cause extra
distress.

The coroner1 has to make decisions about what happens to your child and
to investigate why they died. This guide tries to explain to families what
these processes are, how you may express your wishes and concerns and
communicate with the coroner.

2. Local services

The Senior Coroner for Inner South London covers the boroughs of
Southwark, Lambeth, Lewisham and Greenwich. The court is at 1 Tennis
Street, Borough, SE1 1YD. The main telephone number is 020 7585 4200
and the Fax is 020 7525 6356. You will have a coroner’s officer case
managing the investigation and once allocated you will be given his or her
direct contact details.

Family Liaison Officers (FLOs) 2 are appointed by the Metropolitan Police

Service. Their contact details will be handed to the personal representative
or family of next of kin, on appointment. They are the point of contact for
families for any police investigation (see below).

The Coroner’s Court Support Service3 is a registered charity, who provides

emotional and practical support through trained volunteers to bereaved
families and others who attend hearings at the court. They may be contacted
by Email at: [email protected]

1
See para 3.1; Glossary, Appendix A, p.27
2
See para 4.2;Glossary, Appendix A, p.27
3
Glossary, Appendix A, p.30

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Local Child Death Overview Panels

Greenwich CSC MASH

(Children Social Care Multi Agency Safeguarding Hub) Team:

Tel: 020 8921 3172

[email protected]

Lambeth and CDOP Co-ordinator & SPOC:

Southwark Indra Gavenaite, Southwark & Lambeth Public Health Department

Tel: 0207 525 3105

[email protected]

Lewisham SPOC (Single Point of Contact): Helen Leahey

Tel: 0203 049 2088

[email protected], cc: [email protected]

LSCB (London Safeguarding Children Board):

[email protected]

CDOP’s throughout the UK:

https://www.gov.uk/government/publications/child-death-overview-panels-
contacts

Some support organisations

Cruse Bereavement Care

Tel: 0207 620 3999 (Lambeth)
0208 850 0505 (Greenwich)
Email: [email protected]
[email protected]
Website: www.cruse.org.uk

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The Compassionate Friends

Helpline: 0345 123 2304

Email: [email protected]
Website:www.tcg.org.uk

Child Bereavement UK
Helpline: 0800 028 8840
Email: [email protected]
Website: www.childbereavement.org.uk

Child Death Helpline

Helpline Tel: 0800 282 986
Mobile Phone Free Helpline No: 0808 800 6019
Email: [email protected]
Website: www.childdeathhelpline.org.uk

SANDS (Stillbirth and Neonatal Death Society)

Tel: 0808 164 3332,
Email: [email protected] ;
Website: https://www.sands.org.uk

https://www.sands.org.uk/support-you/how-we-offer-support/useful-links-
and-organisations

The Registrars of Deaths

Contact details for the Registrars’ offices for registering the death are listed:-

Royal Greenwich Registration Services - Book online -

[email protected] OR Telephone 020 8921 5015

Lambeth Registration Service – Book online – www.lambeth.gov.uk OR

Telephone 0207 926 9420

Lewisham Registration Service Book on line – www.lewisham.gov.uk

or Telephone number – 0208 690 2128

Southwark Registration Service Office – Email: [email protected]

or Telephone number 02075257669

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3. The coronial process

3.1 What is a coroner?

A coroner is an independent judicial office holder (a ‘judge”), appointed by

a local authority (council) within specific areas. Coroners are lawyers but
some are also doctors. Coroners work within a framework of law passed by
Parliament. The Chief Coroner4 heads the coroner service and gives
guidance on standards and practice. Locally, the senior coroner is Andrew
Harris and there are seven part-time assistants who all “sit” in the
jurisdiction, so that they share being on call and may be involved in your
investigation.

3.2 Why is a coroner involved in my child’s death?

Coroners have by law to investigate deaths under certain circumstances.

They can only open an investigation into the death of your child when the
body is lying in the jurisdiction5 (Boroughs of Lambeth, Southwark,
Lewisham, Greenwich). This therefore might include a death abroad where
the body is flown into this area. When such a death is reported to the
coroner, an investigation must be begun if the coroner has reason to suspect
that:
• the death was violent or unnatural;
• the cause of death is unknown; or
• the person died while in prison, police custody, or otherwise detained.

The most likely reason for involvement of a coroner in your child’s death is
that a doctor cannot give a medical certificate of a cause of death6, which is
required by the Registrar of Deaths7. Coroners refer to deaths that were not
from natural causes, such as an illness, as ‘unnatural’ deaths. Sometimes it is
clear that the cause is unnatural, such as a traffic accident or drowning, and
sometimes the circumstances of a death from natural causes require
investigation if they give reason to suspect the death was unnatural. For
example something that was done, or not done but should have been done
may appear to have caused death. All these require a coroner to investigate.
4
Glossary, Appendix A, p.27
5
Glossary, Appendix A, p28.
6
Glossary, Appendix A, p.28
7
Glossary, Appendix A, p.29

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The coroner’s investigation does not seek to blame anyone or find an

individual responsible, but it does seek to discover the cause of your child’s
death. Your statements will be important to gather the facts about the
circumstances and help the coroner in asking the right questions and
finding the best evidence.

3.3 What happens first when the death is reported?

Once a death is referred to a coroner (usually by a doctor or police), it is

given to a coroner’s officer8, who will try to contact the family or next of kin
as soon as possible. It is always within 3 working days and is usually more
promptly than this, but sometimes pressures on staff time, over which the
coroner has no control, mean it can take longer. The officer will want to
hear any information or concerns from the family, and will explain next
steps being taken.

Sometimes further information is sought from the referring doctor or his or

her consultant, or others, where a medical cause of death is not given or is
unclear or there is circumstantial evidence. If a death is concluded to be
natural, with no circumstances that need investigation, there will either be
no action and the doctor can issue a certificate, or it is handled by issue of a
Peach Form A9 from the coroner to the registrar. These enable Registration
of the death by the next of kin. A post mortem10 examination may be
ordered, if there is no agreed medical cause of death or the coroner cannot
clearly conclude it is natural (see below). The date will be given – it is usually
in about 3 days. An investigation may be opened and reports sought, or
occasionally an inquest11 opened straight away (see below).

3.4 Organ donation.

If the death of your child is reported to the coroner and there is a wish to
donate an organ to another child, the Senior Nurse Organ Donation
(SN-OD) will inform the coroner through the duty coroner’s officer, that
there is an intention to donate. The coroner has no power to issue any
directions in a situation where the child has not yet died, but may offer
anticipatory advice. The coroner does not have any power to give consent or
8
Glossary, Appendix A, p.27
9
Glossary, Appendix A, p.29
10
Glossary, Appendix A, p.29
11
Glossary, Appendix A, p.28

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refusal of donation. That is a matter for families. However, the coroner does
have the duty of ensuring that evidence that is crucial either to the police of
his investigation is not lost by donation. The coroner often has direct
contact with the nurse or medical team caring for the patient and can
discuss this with them.

To help their investigation and to find out the cause of death, the coroner or
their officer may have to place some restrictions as to what organs can be
retrieved. In cases where there is police investigation, the police will be
consulted and will need to give their permission to the coroner for organ
removal. Where there is a criminal investigation, it may be that the police
will not be able to allow any interference with the body before a forensic
autopsy12. It is less usual for this to be necessary for a coronial investigation
into the deaths of older children, but in small babies with no clear cause of
death, preservation of organs is more important to determine the cause of
death. There may be certain circumstances when a Home Office pathologist
may need to attend the retrieval procedure (obtaining the organ for
donation) to document events and take photographs to help the coroner
with their investigation. Occasionally blood samples will be required by the
coroner at the time of donation.

3.5 The local Child Safeguarding Board (Children Safeguarding Partnership)

The coroner has a statutory duty, that is he or she must in law, inform the
local Child Safeguarding Board (as above) within 3 days after opening an
investigation into a death of anyone under 18. The coroner must share
information from the coronial investigation, regardless of confidentiality,
and the Board and its partners have duties to disclose matters in its
investigation with the coroner. The decision as to what information is
further shared with parents or professionals is a legal one, considered by the
coroner. Essentially information relevant to the inquest is shared.

3.6 Why are the police involved?

The death of any child is a tragedy and every parent has a right to have such
an event properly investigated. Police will attend all instances of sudden and
unexpected death, the Safeguarding Detective Inspector will consider the
circumstances and decide which unit in the police will take the lead in any
investigation. If they are involved a Family Liaison Officer may be appointed
to explain the processes and inform the family (see section 4.2 below).
12
Glossary, Appendix A, p.27

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Just because police are involved does not mean that parents are suspected of
having harmed their child or of being involved in their child’s death. But it
is essential to demonstrate that there is no reason to suspect the parents and
to identify the rare cases where a criminal investigation is necessary. If there
is a criminal investigation, the coroner will suspend his until that is
completed. (see section 4 below).

When a child under 2 years of age dies specially trained officers from Project
Indigo13 will assess the circumstances. Project Indigo was set up to provide a
consistent approach to investigating Sudden and Unexpected Death in
Infancy. Learning shared from Project Indigo investigations have led to
National Campaigns and preventative advice to parents.

3.7 What do coroners do?

The coroner’s investigation is the process by which the coroner establishes

who has died, and how, when, and where they died.
When a death is reported to a coroner, he or she:
• firstly decides whether an investigation is required;
• if so, investigates to establish the identity of the person who has died;
how, when, and where they died; and any information required to register
the death; and
• uses information discovered during the investigation to help prevent other
deaths, where possible.

3.8 May I know what the coroner is doing and contribute to his investigation?

Close relatives are in law interested persons14, which give you rights to express
your views to the coroner about an investigation, to say what you think
should be investigated and suggest what evidence is needed. For example
you may wish the coroner to secure statements from family members or
people who were caring for your child or who witnessed an event. This is
done by communication with the coroner’s officer. These are sometimes
called submissions15. The evidence is collected by statements or interviews
and sometimes there are other reports or exhibits (for example photographs
or mobile phone report). This would usually include autopsy reports, and
often statements from family, police, emergency services and doctors. As
13
Glossary, Appendix A, p.29
14
Glossary, Appendix A, p.28
15
Glossary, Appendix A, p.30

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parents you will have a right to receive copies of the evidence authorised by
the court. That is called disclosure16.

3.9 How does the family communicate with the coroner?

Communications with the coroner are through the coroner’s officer. The
coroner is in court much of the time and as a judicial officer, his
communications with interested persons should in law “be on the record”.
This means the coroner would normally be unable to have private telephone
conversations with interested persons. He or she reads the submissions of
families very carefully and is regularly briefed by the officer looking after the
case. If necessary the coroner can hold a hearing17 in court, when the family
may make submissions directly in person. If a family wish to do this the
opening of an inquest is often a good time to ask to have such a hearing.

Communications between the court and the bereaved are normally carried
out by telephone, email or letter. However, family can always call an officer
to make an appointment to come to the court to discuss their case with
them and raise any concerns they have. Please note this needs to be an
appointment due to the volume of work that is carried out at the court and
an officer might not necessarily be immediately available to see people.

We ask that the family choose one family member to be the person with
whom the coroner’s office can communicate, and who will be given any
disclosures from the coroner. This will be the coroner’s key contact. That
does not remove the rights of other family members, who are interested
persons, to take an active part in the inquest, for example to ask questions.

Where there are conflicts or estrangements in the family, the coroner’s

officer can communicate with more than one family member. Some
communication is necessary by email (for example sending documents or
legal decisions) and so an email address is requested of every family, but
documents can be posted if that is necessary. If families find telephone
discussions helpful, then they can give the officer their phone number.

3.10 What is the role of the Coroner’s Officer?

The Coroner's Officer helps the coroner with the investigation into the
cause of the death. If you have not been informed who is the coroner’s
16
Glossary, Appendix A, p.27
17
Glossary, Appendix A, p.28

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officer for your child’s death, please email the office on this address:
http://www.innersouthlondoncoroner.org.uk/about/i-am-bereaved/general-
inquiry-form

You have probably received an initial phone call or email from the coroner’s
officer. You should be given a telephone number and email to contact the
officer and if you have not, please call the number in s2 above to get the
contact details.

The officer appreciates that you and the family will be deeply traumatised
and may find it difficult to talk about what has happened. They are trained
in communicating with bereaved persons. At all times it is expected that the
officer will listen, show understanding and treat all members of the family
with sympathetic respect as it is appreciated that this is a stressful and
distressing time.

The coroner has a variety of legal obligations of notification to the next of

kin or personal representative of the family. These are all carried out by the
Coroner’s Officer:

a) to try to identify the personal representative or next of kin and tell them
that an investigation has started

b) to let the family know the time, date and place of an autopsy (see below),
where it is practicable and will not cause delay to the examination (in the
case of children in practice this notification always happens).

c) if your child’s body is unable to be released within 28 days, to explain why

this is the case (in practice this only rarely occurs at the request of police in a
criminal investigation)

d) to let you know how long any samples18 taken at autopsy will be kept after
an autopsy and invite completion of a Family Wishes Form, so that you can
say what you would like to do with these. We will let you know when they
have been analysed.

e) let you know if the investigation has been discontinued (stopped), usually
because a natural cause of death had been found.

18
Glossary, Appendix A, p.29

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f) to let you know if the investigation has been moved to another

jurisdiction. This is called a transfer19. It occurs, for example where the death
relates to a car accident in another area.

g) about details of hearings and an inquest and any changes in arrangements

(in practice these are set having considered the convenience and wishes of
the family).

These are only the duties laid down in law. Our officers would expect to
have close communications with your family before many of these formal
duties arise. They would wish to maintain whatever contact is helpful to
parents and family members. It is expected that the Coroner’s Officer will
keep in regular contact with family or next of kin to let them know any
updates on any enquiry, investigation or inquest. They will aim to contact
you every 2-3 weeks, unless their workload makes this difficult. There may be
also times when they cannot give an immediate answer to questions because
they might have to take instructions from the coroner or obtain advice or
information from elsewhere, which could take time.

Officers, on instruction from the coroner, collect together all the relevant
information the Coroner needs, usually mostly in the form of detailed
written statements, so that a decision can be made on what, if any, further
action is necessary.

The family representative will be invited to any hearings and consulted

before any key decisions are made, for example discontinuing an
investigation, opening an inquest or instructing an independent expert.
Relatives will be told of all the coroner’s case decisions and advised about
any steps they should take. Throughout the enquiry, the relative's link with
the Coroner's Office is through the Coroner's Officer.

3.11 Why are there restrictions on my contact with my child? May I hold him or her
or take hand prints?

When any death is reported to the coroner, in law, nothing may be done to
the body of the person who has died without the permission of the coroner.
The principle is that nothing must interfere with the process of finding out
the cause of death and this is especially important where there the death may
involve a third party or be a homicide. Of course, most child deaths are not
19
Glossary, Appendix A, p.30

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suspicious, but it is sometimes difficult, especially in small children, to know

at first whether there needs to be any suspicion. For child deaths under the
age of 18 the general rule in hospital is that the immediate family will be
allowed to remain with their deceased child, but it will always be under
supervision. Although it is very difficult for parents and families, if the
police decide that the death is initially suspicious, parents may only be able
to have limited contact with their child, and no clothing or medical
equipment can be allowed to be removed before an autopsy is carried out.
This is because there is a need to preserve any evidence that may be needed
by a forensic pathologist20, who is appointed to determine whether there is
an unnatural medical cause of death and how it has come about. The
coroner will authorise some tests to be done in hospital before an autopsy,
to help find out if there is a disease present and enable an accurate cause of
death to be determined.

A parent will be allowed to take photographs, as long as they understand

that they may not be posted on the internet or published, until the police or
coronial investigations or inquest have been completed. In non suspicious
deaths, the coroner is generally content for bereaved parents to have
supervised contact with their children in the mortuary and to take hand or
foot prints or a lock of hair, at any time. Please ask if you would like this
and arrangements will be made. Where there are grounds for suspicion or
the cause of death is unknown, the permission of the police may be
necessary first. After an inquest, there are usually no restrictions on contact
or mementos21. There is a Memorandum of Understanding, which explains
these arrangementsi.

Normally the child who has died is seen by the family after death to establish
his or her identity, which is a legal requirement of the coroner’s
investigation. The family or next of kin are invited to come to the mortuary
where their child’s body is held, to do this and they will meet a coroner’s
officer at the mortuary, who will take them through the process. Informal
viewings are normally not allowed because mortuaries are fully working
mortuaries and do not necessarily have the staff to allow for this to happen.
However in the case of deaths of children under the age of 18 years every
attempt will be made to allow this to happen. These viewings take place
normally behind glass but if a prior request has been made for contact,
arrangements can be made.

20
Glossary, Appendix A, p.29
21
Glossary, Appendix A, p.28

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3.12 Does my child have to have a post mortem examination (autopsy)?

Post Mortem Examinations (“PM” is Latin for “After Death”) or autopsies

are almost always necessary in deaths where there is no known cause. The
post mortem examination will take place as soon as a pathologist is able to
carry it out, normally within 5-7 working days of the death being referred to
the Coroner. Most autopsies involve examining the outside and inside of the
body. This is done with as much care as it would be if your child was having
any operation. Sometimes blood tests, samples looking for infection, looking
at tissues under a microscope or a scan or X-rays are done. Please talk to the
coroner’s officer if you have special wishes or concerns. In law, the Coroner
is the only person who can authorise a post mortem examination when a
death is reported to the coroner, and would want to consider any objections
or special requests the family has, before making the decision.

Where a death may be suspicious, involving a third party, the police will
request the coroner orders a special forensic autopsy, in which many more
tests are ordered. What tests are done is a matter for the pathologist
conducting the autopsy.

3.13 What is the role of pathologists?

Pathologists are not part of the coroner’s staff. Autopsies on children are
carried out by specially trained paediatric pathologists22, that is doctors who
have specialized in identifying the causes of death in childhood. They are
each individually appointed by the coroner, after a process of assessment and
independent professional accreditation to conduct autopsy work. They are
guided by the standards of practice of the Royal College of Pathologists and
engage in a process of peer validation of the work, just like clinical doctors.
They are professionally accountable to their regulatory body, The General
Medical Council.

Their task is to find out the medical cause of death. Some work from a
public mortuary and others from a hospital mortuary, but for coronial work,
they are independent from the hospital. For suspicious deaths, where there
is a possibility that a crime has been committed, the police will request the
coroner to appoint a forensic pathologist who is registered with the Home
Office, as well as a paediatric pathologist.

22
Glossary, Appendix A, p.29

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3.14 What tests are done?

As part of a post mortem examination, a pathologist will often want to carry

out further testing on samples that are taken from the person who has died
during the autopsy. These samples are sent by the pathologist via the
mortuary to laboratories who will carry out the tests. There are many types of
samples that are taken. Examples are to detect signs of an infection or a
disease. Poisoning is investigated by toxicology (testing fluids such as blood,
urine for drugs and substances) 23.

Tissue fragments may be taken (such as sections of liver, kidney, heart) and
they are looked at under a microscope. This is called histology24.
Occasionally a whole organ is examined, such as a heart or brain. The
transport, testing, reporting and analysis of toxicology tests takes up to 6
weeks. Histology may take a few weeks or many months for the final analysis
to be completed and reported.

Once the pathologist receives the results back, he or she finalises the autopsy
report and sends it to the coroner. The coroner has little control over how
long it takes these reports to be completed, although there is a
Memorandum of Understanding that normally paediatric autopsies should
be completed in 4 monthsii. When the delay is excessive and without
explanation, the Court may issue an Order for the report to be produced.

3.15 The provisional post mortem examination report

Once a post mortem result is known the Coroner’s Officer will be in contact
with the family or next of kin to let them know the provisional result, if
there is one. This would normally take place within 24 hours of the post
mortem being carried out. It may say something like “multiple injuries”,
“congenital heart disease” or “under investigation”. It will be at this time
that the Coroner’s Officer will discuss with the family representative, if
samples have been taken at autopsy, how long it will take for the results of
the tests to be available and when the full post mortem result will be
available.

The report on a standard paediatric autopsy may take about 3 – 4 months to

complete. The report on a forensic autopsy may take from 6 – 9 months to
complete.
23
Glossary, Appendix A, p.30
24
Glossary, Appendix A, p.28

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3.16 Family Wishes for samples

Also at this time the officer will discuss with the family representative how
would they like the samples to be disposed of, once the testing is complete,
and this will always be confirmed in writing by the person giving those
instructions (“Family Wishes”). If anything is kept for additional
examination, the coroner will let the next of kin know how long they are to
be kept, and ask what they wish to happen to the samples when no longer
required. When these are no longer needed for the coroner’s investigation
they will either be kept as part of the pathology record or returned to the
child’s family or representative, if requested, or disposed of by burial or
cremation. If a pathologist believes it would be appropriate to keep organs
and tissue, for example for use in research or for training purposes, he or she
must obtain your consent. In exceptional cases, e.g. involving murder,
samples may have to be kept for a longer period.

3.17 Release of your child’s body

Arrangements for the funeral cannot be made without confirmation from

the Coroner's Officer that your child’s body can be released for burial or
cremation. In certain circumstances, an investigation may need to be started
or an inquest may need to be opened before authorisation can be given for
your child’s body to be released. Where an investigation is opened, the
coroner’s officer can, on request, issue an of the fact of death certificate,
enabling the funeral to take place.

The coroner has a duty to release your child’s body at the earliest
opportunity so that you can hold their funeral. In most cases this can be
carried out fairly speedily once a death has been referred to the coroner
(such as when the coroner can inform the Registrar that this is a natural
death). Unless there is a criminal investigation, it is rare for a child’s body
not to be released as soon as identification and the autopsy have been
completed and the ID form signed. Once a child’s body has been released,
the family’s undertakers will be able to ask the coroner for the forms they
need for the funeral (cremation, burial, or Out of England).

Where there is a criminal investigation being carried out by the police, the
coroner may not release a child’s body until any defendant who has been
charged in connection with the death has had an opportunity to have their

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own post mortem examination, and the police confirm that they agree to the
body being released. The coroner appreciates that this delay may cause
distress to the family, but he or she has to respect legal rights. A court
hearing with the police and interested persons may be ordered after 28 days
if permission for release has not been granted.

3.18 Communicating the results of the full Post Mortem Examination report

Once the full Post Mortem Examination report is received by the Coroner,
the Coroner’s Officer dealing with the case will communicate the result to
the family or next of kin. The report will be full of details that can be
distressing to read, and include much medical language that can be difficult
to understand. This can be fearful and daunting to receive. You may wish to
talk to your family to see what would work best for you. We will try to do
this in the way that best suits your family. There are a number of options:

1. By telephone and then mail

A summary of results can be communicated by phone and then the full

report posted or emailed. It should be also noted that Coroner’s Officers are
not medically trained so that they cannot interpret fully the post mortem
reports25. They can inform you of the medical cause of death (which is
intended to go to the Registrar of deaths). You can be told whether the
toxicology results are negative or positive. The officer will not be able to say
whether it means there will be an inquest unless the coroner has already
taken a decision to discontinue or inquest. Usually families are asked for
their views, but sometimes there is no doubt in law.

2. By appointment

You may wish to make an appointment and come to the court and speak in
person to the officer, who can give you a summary of the report and then
hand the full report to you. Again, there are limits to how much the officer
can interpret the report, but if you are choosing to attend the court offices,
the officer can speak to the coroner to find out if there is any additional
information or questions for the family. It may create an opportunity to ask
things that occur to you, when you are in somebody’s company.

25
Glossary, Appendix A, p.29

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3. A letter may be sent by post.

This is usually done by having a letter from the officer explaining that in a
separate envelope, clearly marked “Post Mortem Report”, is the full autopsy
report, which may be distressing to read and difficult to understand, and
that you might like to have family with you or arrange for a medical friend
or GP or hospital doctor involved in care to explain it to you.

4. The report can be emailed.

Again, as this may be distressing to read and difficult to understand, you

might like to have family with you or arrange for a medical friend or GP or
hospital doctor involved in care to explain it to you. It may be helpful to
have the report emailed, when you are intending to send a copy to someone
such as your GP or to a relative.

However, the post mortem report is a confidential document. It should not

be disclosed under any circumstances without the coroner’s written approval
to the media or be used on social networking sites. The report is to be used
by the coroner and interested persons (IPs), solely for the purposes of
informing IPs and preparation for the Inquest and no further.

3.19 Understanding the full post mortem examination report

The medical cause of death is given in the report. It is suggested that this is
the first part to read. It is a chain of causative events. It is expressed thus:

1a The immediate cause of death

1b What has caused 1a
1c Anything that has caused or led to the cause at 1b
II Conditions which have contributed to the death, but are not directly
related to those in I.

If there are any positive toxicology results, they will only have contributed to
death, if they are included in the above medical cause of death. The next
part to read is the conclusion, which explains how the pathologist has
reached his or her conclusions and usually summarizes the opinion. The rest

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is detailed description of organs, microscopy and other tests, which may be

distressing and difficult to understand.

The family might wish for sections of a post mortem to be clarified or may
have concerns about the report itself or be able to contribute to matters
raised by the pathologist. All queries should be raised with the Coroner’s
Officer who can then send them to the pathologist for answering.

When an inquest is held, either some part of the autopsy report will be read
out in court, or the pathologist may give evidence in person. The latter may
happen when the cause of death is contested (for example a clinician may
have a different view), when the details are too complex to understand or
where the family wish to question the pathologist. The bereaved will be
given the opportunity to state whether they wish to excuse themselves from
this part of the proceedings or remain to hear it all.

3.20 Who are interested persons and what rights do we have?

The close relatives of the person who has died have a special status in
coronial law. They are known as interested persons (IPs) and have the
particular rights. A deceased child’s parents are automatically IPs. The
coroner will also regard adult brothers and sisters as IPs. If the next of kin is
a more distant relative such as a grandmother, the coroner will usually grant
them that status as well. Before the inquest hearing, IPs can request
disclosure. This means sharing copies of all the reports and statements,
reports and exhibits evidence. Disclosure might include medical records,
policy statements, videos etc. Disclosing them does not mean they will
necessarily be part of the inquest or be shown in court. It is unusual for
anything to be shown in court – sometimes a photograph might be. IPs may
make submissions to the coroner about any of these matters.

When the coroner is presiding in court, it is called hearing. At any hearing,

including pre-inquest reviews26 or the inquest itself, IPs may make
submissions to the coroner. In the inquest, they may ask questions of the
witnesses. IPs have the right to be legally represented if they choose. This is
not necessary but some parents consider it if proceedings are very complex
and issues are contested. After the inquest, IPs may request copies of the
documents, if they did not have them beforehand.

26
Glossary, Appendix A, p.29

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Other people may also be granted IP status for different reasons, which
include when they are being criticised as possibly being involved or
contributing to the death. Examples are doctors treating a child, a person or
organization charged with the child’s care, or a car driver in an accident. All
IPs have the same rights.

3.21 Stopping the investigation (Discontinuation)

After receiving the post mortem report, the coroner may decide to stop
(discontinue) the investigation. The coroner’s officer will inform you if the
coroner has made any decisions on receiving the report. If it is obviously an
unnatural or violent death an inquest must be opened in law. He or she may
seek your submissions27 about what he or she should do on receiving it. If
there is scope to consider whether or not to discontinue the investigation,
the coroner will ask for the views of interested persons.

If matters are complex or the family particularly wish, a pre-inquest hearing

may be held in court, to explore the way forward. Parents or a representative
if the family can attend and make submissions. This can be particularly
helpful where another person or organization is being criticised as being
involved in the death, or the circumstances and cause of death are not clear,
and further investigation are needed.

If an investigation is to be discontinued the Coroner’s Officer will send the

Coroner’s form to the Registrar to enable the family’s personal
representative or next of kin to register the death. However if the family are
not satisfied with the cause of death, then they are able to write into the
court to express their concerns before registering the death with the
Registrar. The coroner will respond to these concerns either to state that
they do not raise any further evidence to show why the death cannot be
registered, or that they do raise new evidence that might have to be
investigated further.

3.22 Transfers to another coroner’s jurisdiction

Sometimes a events relevant to the death happen in a different coroner’s

area (or jurisdiction) to the one where your child died, such as when a road
traffic victim is transferred from the scene, to a hospital within this coroner’s
area in London. As the event leading to the death happened elsewhere, then
the coroner where the body of your child is lying, will ask the coroner whose
27
Glossary, Appendix A, p.29

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jurisdiction covers the scene of the tragedy to take control of the

proceedings. This can take a few days to complete, as it is a formal
documented request and both coroners have to agree to the transfer taking
place. Normally this takes 2-3 working days.

3.23 Opening an inquest

The coroner may only discontinue an investigation into a death when the
autopsy report enables the coroner not to have reason to suspect that the
death is unnatural, and where there is no need to continue the investigation.
If it is not discontinued, an inquest must be held. Sometimes this is
apparent before an autopsy, but more commonly the decision rests on the
coroner’s judgement of the implications of the autopsy report. It may be
necessary to get further reports, such as from hospital doctors, before the
decision is made. The family’s views are important and will be considered.

An Inquest must be formally opened in court. All court hearings are in

public. Family, next of kin and any interested persons are informed of the
date, should they so wish to attend. The opening will usually consist of a
brief report from the coroner’s officer as to the death report, the evidence of
identification and the provisional or final report from the pathologist. It
usually includes brief reference to the circumstances of how the death
happened and if the police are involved a statement from them as to the
circumstances. The opening is not the Inquest hearing itself.

Once an Inquest has been opened the next step is to set a date for the final
hearing of the inquest. If parents do not attend the opening, they will be
informed of the listing date, often by email. Usually it is in about six months
time, but the period may be longer in complex cases. Please inform the
coroner’s officer of dates or times to avoid, due to leave, a child’s birthday or
unchangeable commitments, if possible before the opening, so that it can be
listed at a convenient time for the family. Listings are on our website.

3.24 Suspending an investigation

If evidence is found that suggests someone may be to blame for the death,
the coroner must pass all the evidence gathered to the police or Crown
Prosecution Service. The coroner is under a legal obligation to suspend his
or her investigation if the police are conducting a criminal investigation and
expect to charge a person with a homicide offence.

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If this is the case, then the Inquest might not be resumed at all if the
relevant evidence has been heard, but it can be resumed after a trial, if there
is one, and if there are grounds to do so. There are other organizations such
as the Fire Service, Care Quality Commission and transport regulatory
agencies, which have power to prosecute and may request a suspension by
the coroner. Also to note, under certain circumstances the coroner might be
asked to suspend an investigation in any event by a governmental body, such
as the Health & Safety Executive pending their enquiries.

3.25 The media

The coroner’s court will publish a list of cases that are being heard and the
public and media are entitled to attend all hearings. If there are matters,
which the family consider sensitive and would prefer not to be aired in
court, please inform the coroner’s officer, so that the coroner can consider if
they are relevant to the inquest or can be excluded from the hearings. The
coroner may avoid reading the whole address of the family at the opening to
preserve some initial privacy for bereavement28.

3.26 Holding a Pre-Inquest Review Hearing (PIRH)

Sometimes a pre-inquest review hearing is listed, where the coroner will

invite all of the Interested Parties to attend to hear their submissions and to
determine what steps are needed to progress the investigation, the scope of
the inquest, what evidence and witnesses to call. Sometimes families are
keen to have more answers from a hospital or carer, that fall outside the
scope of an inquest, and the family can be signposted to the “PALS” 29 or
complaints and investigation processes of hospitals, the Care Quality
Commission or other organizations.

An agenda is usually issued before these hearings. It is really helpful,

wherever possible, if you can provide the coroner’s officer with the
background information about the death and your family’s views and
requests or answer any questions raised by the coroner, before the hearing.
For example, if the family have concerns about the way a child was treated
during the events leading up to the death, then the family should bring these
concerns to the attention of the coroner via the coroner’s officer, as soon as
possible, so that the coroner can take them into consideration when
28
https://www.innersouthlondoncoroner.org.uk/about/information/media-policy.
29
Glossary, Appendix A, p.30

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preparing the inquest for the final hearing. It creates real difficulties if new
evidence and concerns are raised for the first time at the final hearing. For
example it may then be too late to call a new witness. So families are asked
to cooperate by sharing their concerns with the officer early in the
investigation, to try to avoid this.

Pre-Inquest Review hearings can be requested by Interested Persons through

the Coroner’s Officer, at anytime, setting out the grounds for the request.
In straightforward investigations, this will not usually be necessary, as
matters can be dealt with by letter or email. But where there are many
interested persons, or new evidence which might cause argument or
controversy, and requiring decisions about further investigation or doubt
about the cause of death and other complexity, they may be useful.

Once a Pre-Inquest date or Inquest hearing date has been arranged there
may be circumstances where these dates might have to change such as
witnesses not being available, or next of kin being out of the country. The
Coroner’s Officer will advise all interested parties when this happens and
will arrange a new date with the coroner.

3.27 The 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. A coroner may not
make statements on other matters, such as judging standard of care of a
child. Inquests into the deaths of children are almost always without a jury,
but there are rare occasions where a jury is required in law. If this is a
possibility the coroner will raise it in a PIRH.

An inquest is different from other types of court hearing because there is no

prosecution or defence. Any lawyers appearing for other IPs are duty bound
to assist the family if they need legal advice and are not legally represented.
The coroner is well used to ensuring fairness, if one IP is and another is not
represented. The purpose of the inquest is to discover the facts of the death,
not to identify blame. This means that the coroner (or jury) cannot find a
person or organisation responsible for the death.

The main inquest hearing should normally take place within six months or
as soon as practicable after the death has been reported to the coroner.
Sometimes you may need to wait longer than six months for the inquest due
to the complexity of the case or other factors (for instance an investigation

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by another organisation). If so, the coroner’s office will be able to keep you
updated on progress.

An inquest may be read, that is it may be held with nobody giving evidence.
This happens when the IPs agree on the evidence and there is no matter
needing further exploration and the family does not wish to question any
witness. The family will be told if this is the case by the coroner’s officer, and
will be asked to inform them whether they wish to attend the read hearing
or not, and to confirm that they are content for the inquest to be read.

If witnesses are to be called to give evidence at an inquest, a parent is likely

to be called and usually the coroner takes the family member through his or
her statement and confirms the documented identification. It is unusual for
family members to be questioned by other IPs in court, but where matters
are contentious this may occur. Parents or their representatives will be able
to ask questions of other witnesses at inquest. The usual format is that the
witness will give evidence first, the coroner will ask them questions and then
give IPs the opportunity to ask theirs.

The coroner will assist the family when it comes to submissions at the end of
the evidence about how the coroner should complete the Record. The
record of Inquest is a public statement about who died, where, when and
how they died. This may be by “short form conclusion” 30 (e.g. accident,
suicide, natural death) or by a narrative31, which explains in more details the
circumstances of the death. All IPs and the media are entitled to a copy of
this document. It enables the death to be formally registered.

3.28 Preventing Future Deaths

The coroner has a formal legal duty to consider whether to make report to a
person or organization, to Prevent Future Deaths32 in the future. Where
there was an adverse incident, evidence will be called during the inquest to
find out what steps have been taken to reduce the likelihood of the incident
being fatal in the future. In some inquests an organization will have
conducted their own incident enquiry and a report will be available to
families. Families will be able to make submissions at the end of the

30
Glossary, Appendix A, p.30
31
Glossary, Appendix A, p.28
32
Glossary, Appendix A, p.29

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evidence as to whether the coroner should make a report or whether the

steps taken have adequately reduced or eliminated the risk.

3.29 Registering the death

If the death is referred to a coroner for whatever reason, and if the Coroner
decides at the outset that the death is a natural one, he/she will direct that
the Registrar of deaths will be informed by the issuing of a Peach Form A to
the Registrar. We also inform the hospital or GP and they will ask the family
to collect the Medical Certificate of the Cause of Death from the doctor and
take it to the Registrar. The death is registered within 5 days.

If the Post Mortem Examination (autopsy) result shows the cause of death to
be a natural cause then again the coroner will direct that the Registrar of
deaths will be informed by the issuing of a Pink Form B to the Registrar.
The family are asked to make an appointment with the relevant Registrar to
register the death. The death is registered within seven days.

If however the autopsy does not find a natural cause of death then it is at
this point Interim death certificates can be issued to a family or next of kin
or the legal representative of the child. These are legal documents to prove
death and do not get taken to the Registrar. They enable the child’s executor
to deal with their estate, such as closing accounts, discontinuing benefits,
dealing with insurance companies or fulfilling any of the child’s legal wishes.
Please note that not all institutions accept these interim death certificates
and may require the coroner’s confirmation or for the family, next of kin or
legal representative to wait until the Inquest is heard.

Once an Inquest has been heard and the coroner has reached a conclusion
then that a Form 99 with the conclusion is passed on to the Registrar33. The
Registrar registers the death without the family attending. Once it has been
registered, the family, next of kin or legal representative can request copies
of the death certificate.
In the unusual event of the registration being more than a year from death,
there is an added delay in the process as Registration requires authorisation
of the national General Registrar’s Office.

33
Glossary, Appendix A, p.29

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4. The police process

4.1 What happens when there are on-going police investigations?

If the police are investigating any death with the intent of charging a person
or persons with a criminal offence, they may apply to the coroner to suspend
the coronial investigation, until such times as their investigation is complete.
This is not an indefinite halt on the inquest as the coroner may some
months later, (in practice usually 9-12 months or more) and in the absence
on anyone being charged with a criminal offence, resume the coronial
investigation and decide to hold an inquest. The family will be consulted
prior to the decision as to whether to resume.

If an inquest does follow a criminal trial, it may be more limited in the

witnesses it calls or it may call new witnesses to investigate matters not raised
at trial. The inquest may not in law reach a conclusion which is different
from the criminal trial.

4.2 What is a Family Liaison officer

If there is a police investigation then a Family Liaison Officer may be

appointed. The FLO will be a serving police officer, to liaise between the
family; and the police and the coroner. The FLO and coroner’s officer will
liaise to agree their respective roles.

The FLO is responsible for passing appropriate information about the

enquiry to the family, and will usually be responsible for taking statements
from the family, relating to identification of your child, and lifestyle, things
they liked to do, the kind of person they were. The FLO will make
arrangements to meet the family as soon as possible.

The FLO will liaise with the Coroner’s Officer to inform the Next of Kin of
autopsy arrangements although they will not attend it in person. Following
the autopsy they will, where possible, meet with the family to explain the
broad findings and explain any issues in relation to the Human Tissue Act.
The FLO will also liaise with the Coroner’s Officer regarding viewing of the
body and subsequent release of the body.

The FLO will liaise with the Coroner’s Officer with regard to the Inquest
and will facilitate the attendance of the family and interested parties. At the
conclusion of the inquest the FLO will ensure all personal property

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belonging to the deceased is restored to the Next of Kin or other nominated

person.

4.3 What support is available if my child has died violently?

Neither Coroner’s Officers, nor Police officers are in a position to provide

full practical support and guidance when working with victims’ families. The
FLO may refer the family to another agency if he or she finds that the family
requires support and assistance with a variety of issues, for e.g. trauma of
bereavement, funeral arrangements, financial or legal advice, or health or
social services advice. There are a number of agencies and networks34 that
can provide assistance at both the national and local level, such as Victim
Support, Support After Murder and Manslaughter (SAMM) and BrakeCare.
The FLO can provide contact details.

34
See para 2. Local services, Support organisations

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Appendix A

Glossary

Common medical and legal terms and names of organizations

Chief Coroner: The Chief Coroner, an office created by the Coroners and Justice Act
2009, is head of the coroner system, providing national leadership for coroners in
England and Wales.

Coroner: An independent judicial official, of a county or municipality (the area is called

a jurisdiction), whose chief function is to investigate and sometimes inquest, any death
not clearly resulting from natural causes.

Coroner’s officer: Coroners’ officers may be serving police officers or civilian police staff
or they may be local authority employees. Coroners’ officers work on behalf of and at the
direction of coroners. They conduct the investigation directed by the coroner. This
involves making inquiries into the circumstances of deaths and collecting statements and
evidence.

Certificate of Coroner (Cremation Form 6) : When there has been a coroner's post-
mortem or there is to be an inquest and the person is going to be cremated. This is
usually collected by the funeral director on your behalf.

Disclosure: Disclosure is the process of sharing information relevant to an investigation.

A coroner must normally disclose copies of relevant documents to an interested person,
on request, at any stage of the investigation process. Documents include; post-mortem
examination reports, witness statements, submissions, recording of hearings, other
reports that have been provided to the coroner during the course of the Investigation and
the Record of Inquest.

Family Liaison Officers: Where the police investigate a death, they have a positive duty
to communicate with the bereaved family. Normally a Police Family Liaison Officer
(FLO) has this role.

Forensic autopsy: A forensic autopsy is a more detailed and long process with many
ancillary tests, photographs and a lot of histology, carried out when the cause of death
may be a criminal matter.

Forensic pathologist: A branch of medicine used for legal purposes and concerned with
determining the cause of death, examination of injuries due to crime and negligence, and
examination of tissue samples relevant to crimes.

Form 99, Certificate After Inquest : This form is completed after an inquest,
incorporating the details within the Record of Inquest, and other statutory details
required by the registrar, to whom it is sent, in order to register the death.

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Hearing: A legal proceeding in which evidence is taken and arguments are given as the
basis for a decision to be issued, either on some preliminary matter or on the merits of
the case. They are likely to be more informal when a child death is involved and where
issues are not contentious.

Histology: The branch of biology dealing with the study of tissues structure, especially the
microscopic structure, of organic tissues. Autopsy pathologists take tissue samples for
study, sometimes to identify what happened in the body that led to death.

Inquest: An inquiry by a coroner held in public in a Coroners Court on the record, to

determine who died, when, where and how the death occurred.

Interested Persons (IPs): They are people and organizations appointed by the coroner,
according to statute in an investigation and inquest. Immediate family members are
automatically always IPs, even if some other relatives object. Apart from immediate family
members, IPs may include doctors and other health care professionals who were involved
in the care of the deceased, someone who witnessed an accident, and anyone criticized in
the circumstances leading to the death. You can apply to be an IP. IPs have rights, which
include receiving disclosure, the right to attend and make submissions in hearings, and to
play an active part in the inquest hearing.

Jurisdiction: The territory over which the legal authority of a court or other institution
extends.

Medical Certificate of a Cause of Death: An official UK certificate which enables

registration of a death with the Office of National Statistics. The certificate provides a
permanent legal record of the fact of death, and enables the family to arrange disposal of
the body and settlement of the deceased’s estate.

Mementoes: An object kept as a reminder of a person or event.

Narrative Conclusion : This may be used as an alternative to a short-form conclusion,

and will be included within box 4 of the Record of Inquest. It is one or more sentences
explaining how the child came by his or her death. They are used when the death is
multi-factorial or complex. The guidance states that a narrative conclusion should be ‘a
brief, neutral, factual statement and it should not express any judgment or opinion’.

Notification by the Coroner (Pink form B / Form 100) : If the coroner has ordered a
post mortem examination but there is no requirement for an inquest, the coroner will
send this to the registrar.

Order for Burial (Form 101) : When there is to be an inquest and the person is going to
be buried the coroner has to give permission for the funeral to proceed.

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Paediatric pathologist: Paediatric pathology is the sub-specialty of pathology which deals

with the diagnosis and characterization of diseases of children. Paediatric autopsy
pathologists work closely with adult autopsy pathologists and with paediatricians.

Peach Form A: This is a form from the coroner informing the registrar that they are
aware of the death but no further investigation is necessary and permission has been
given to the doctor to issue the Medical Certificate.

Post-mortem Report: The final report of the findings by a pathologist following an

autopsy. It is confidential to the coroner, who shares it with interested persons and not
the public.

Post-mortem Examination: an examination and dissection (carried out by a pathologist)

of a dead body to determine cause of death. It is also called an autopsy.

Pre- inquest Review Hearing (PIRH): A PIRH will be held if there are particular issues
of law or procedure that need to be determined by the Coroner before the final inquest.
They are often used to hear the concerns or suggestions of families and to explain the way
forward in an investigation.

Prevent Future Deaths: Paragraph 7 of Schedule 5, Coroners and Justice Act 2009,
provides coroners with the duty to make reports to a person, organisation, local authority
or government department or agency where the coroner believes that action should be
taken to prevent future deaths. This may be done during an investigation or at the end of
an inquest. Families may make submissions to the coroner about this.

Project Indigo : Set up to provide a consistent approach to investigating Sudden and

Unexpected Death in Infancy.

Registrar: An official responsible for keeping a register or official records

Removal Notice (Form 104) : When the body is going to be moved out of England and
Wales. This is sometimes called the ‘Out of England' form

Samples: During a standard post-mortem examination the body is opened and organs are
removed for examination. Most of the time, a diagnosis can be made by looking at the
organs, and they will then be returned to the body. However, in some post-mortem
examinations, the cause of death is not immediately known. A diagnosis can only be
made by retaining small tissue samples of relevant organs for more detailed examination.
The Pathologist may occasionally need to retain a whole organ for a full assessment to
allow an accurate diagnosis of the cause of death to be made.

Submissions: A proposition or argument presented by counsel to a judge or jury or

interested person for consideration or judgement. A submission from a parent does not
need to be formal or in writing (although that is always helpful). It can be little more than
a wish or an expression that something should be part of the investigation or inquest.

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Short form conclusion: The Chief Coroner issued national guidance (number 17) iiito
all coroners, to ensure that the conclusions returned at the end of each inquest are clear
and consistent. Wherever possible, coroners are asked to return short form
conclusions. The Chief Coroner suggests the following, but coroners are not limited to
these: Accident or misadventure, Alcohol/drug related, Industrial disease,
Lawful/unlawful killing, Natural causes, Open, Road traffic collision and Suicide.

The Patient Advice and Liaison Service ( PALS): PALS are NHS advice services. They
offer confidential advice, support and information on health-related matters. They
provide a point of contact for patients, their families and their carers. They may be
helpful in understanding clinical care or handling a complaint about hospital care.

The Coroner’s Court Support Service: A registered charity, which provides emotional
and practical support through trained volunteers to bereaved families and others who
attend hearings at the court

Toxicology: Toxicology is the scientific study of adverse effects that occur in living
organisms due to chemicals. It involves observing and reporting symptoms, mechanisms,
detection and treatments of toxic substances, in particular relation to the poisoning of
humans. Autopsy pathologists take samples such as blood, saliva, and urine to determine
whether death was related to poisoning or intoxication.

Transfer: Transfers of cases from one jurisdiction to another, in England & Wales. The
Chief Coroner has issued guidance 24, which sets out the position on transfers and
provides advice on when it is appropriate to request a transfer.

i
Memorandum of Understanding concerning application of Kennedy guidelines to investigation of deaths of children
bought to Accident and Emergency Departments (Currently in press)

iiSenior Coroner, London Inner South Memorandum of Understanding between the Senior Coroner and approved
pathologists and other suitable practitioners
V9, October 2016 https://www.innersouthlondoncoroner.org.uk/about/information
iii
https://www.judiciary.gov.uk/related-offices-and-bodies/office-chief-coroner/pfd-reports/
iii
https://www.judiciary.gov.uk/wp-content/uploads/2016/10/guidance-no-24-transfers.pdf
iii
https://www.weightmans.com/insights/coroners-forms-and-investigation-process-explained/
iii
https://www.judiciary.gov.uk/wp-content/uploads/2013/09/guidance-no-17-conclusions.pdf

Thanks are given to many contributors and editors. In particular we should like to thank Fiona Spargo-
Mabbs, Fiona Martin, Shaneeka Powell, Fahimul Salman, Maher Nizari, Helen Leahey and Jenny Taylor

AH and DL

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