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A coroner is a person whose standard role is to confirm and certify the death of an individual within a jurisdiction. A coroner may also conduct or order an inquest into the manner or cause of death, and investigate or confirm the identity of an unknown person who has been found dead within the coroner's jurisdiction.


In England, where the role originated, a coroner also deals with treasure trove cases. 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.

The word coroner derives from the same source as the word crown, and denotes an officer of The Crown. The Spanish etymological cognate for a crown officer, coronel, designates a colonel.

Coroner masked jackal

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.

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 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.

In Middle English, the word "coroner" referred to an officer of The Crown, derived from the French couronne and Latin corona, meaning "crown".


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

The 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. 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." 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. 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.

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


In 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. While the title differs, however, they act in similar capacities. 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 or Medical Examiner services are under the jurisdiction of provincial or territorial governments, generally 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.

The provinces of Alberta, Manitoba, Nova Scotia and Newfoundland and Labrador 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, and Ontario, 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.

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:

  • 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.


    The Coroners Service is a network of Coroners situated across Ireland, usually covering areas based on Ireland's traditional counties. They are appointed by local authorities as independent experts and must be either qualified doctors or lawyers. 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.

    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:

  • Established the office of the chief coroner to provide leadership and coordination
  • Moved to a smaller number of full-time legally-qualified coroners who are Judges of the Coroners Court
  • Ensured families are notified of significant steps in the coronial process
  • Introduced wide-ranging cultural matters to be considered in all aspects of dealing with the dead body
  • Introduced a specific regime for attention and release of body parts and body samples
  • Enhanced inquiry and inquest processes
  • England and Wales

    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.


    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 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. Those 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.


    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. A senior judge is sometimes appointed 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.


    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 coroner's former power to name a suspect in the inquest verdict and commit then for trial 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:

  • 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
  • See also (English Coroner)

  • Coroner's jury
  • Forensic pathology
  • Medical examiner
  • Notes (English Coroner)

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

    The verdicts of suicide and unlawful killing 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.

    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. 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).

    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.


    In Scotland there are no longer coroners. Coroners were used in Scotland between about 1500 and 1800 when they ceased to be used. 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.

    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. 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, although a coroner may overrule a forensic pathologist in naming a cause of death. Some coroners are elected, and others 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 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 forensic pathologist or even a pathologist; physicians with no experience in forensic medicine have become medical examiners. In others, such as Wisconsin, each county sets standards, and in some, the medical examiner does not need any medical or educational qualifications.

    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.

    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. In some places in the United States, a coroner has other special powers, such as the ability to arrest the county sheriff.


    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, in addition to conducting cause and manner of death investigations and inquests, the coroner officially acts as sheriff for the county. This is also the case in Colorado. Also in North Carolina, the coroner exists in approximately 65 counties by law, but is only an active office on ten. 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 North Carolina, in the counties that have coroners, they are set forth as common law peace officers, yet the coroner of the county also has judicial powers; not only to investigate cause and manner of death, but to conduct inquests, issue court orders, to empanel a coroner's jury and to act as Sheriff in certain cases or even arrest the Sheriff for cause. Beginning in 2015, the NC Office of Chief Medical Examiner (OCME) began optional training for coroners to become special assistant medical examiner investigators (NC CH130A & 152). In New York City, the office of coroner was actually abolished in 1915, since before that time, having medical knowledge was not actually a requirement, leading to much abuse of position.

    Non-Britannic equivalents

    The equivalent offices in other nations not evolved from the office established in the British Isles include:

    In Japan, the equivalent of the coroner's office assists with investigations. Members of the 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.

    Notable coroners

  • Larry Campbell
  • John C. Fleming
  • J. Howell Flournoy
  • Alexander Fulton
  • Morton Shulman
  • Charles Norris
  • Thomas Noguchi (born 1927) former Chief Medical Examiner-Coroner for the County of Los Angeles
  • Film

  • 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

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

  • M. R. Hall is a British crime novelist, who writes a series of best-selling novels featuring Bristol-based coroner, Jenny Cooper.
  • 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.
  • 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

    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.
  • ABC's Body of Proof, starring Dana Delany as Dr. Megan Hunt, is about a medical examiner in Philadelphia, Pennsylvania.
  • The lead character in the television series Crossing Jordan is a medical examiner.
  • The coroner is a significant character and a main cast member on CSI: Crime Scene Investigation and its spin-offs CSI: Miami and CSI: NY.
  • 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 Orange and Osceola Counties in Florida and Bexar County, Texas.
  • The American police procedural drama series Hawaii Five-0 features a coroner named Dr. Max Bergman, played by Japanese-American actor Masi Oka.
  • Dr. Donald "Ducky" Mallard, portrayed by actor David McCallum, is a fictional medical examiner on the American television crime drama NCIS.
  • Kurt Fuller plays Woody, a Coroner on the American sitcom Psych.
  • The television series Quincy, M.E. has a coroner as its title character.
  • 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 Wojeck (the Canadian ancestor of Quincy, M.E.) has a coroner as its title character, inspired by the coroner Dr. Morton Shulman.
  • Dr. Camille Saroyan. Is a federal coroner and the Head of the Forensic Division at Jeffersonian Institute in the TV series "Bones"
  • References

    Coroner Wikipedia

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