1. Coroners Investigation (It’s not Silent Witness)
© Eastbourne Coroner's Office
© Mrs A Warner Coroner's Officer 2009

2. © Eastbourne Coroner's Office
History
Medieval tax gatherer
‘The Crowner’
Over 800 years old
Stamp out the clandestine murder of Normans
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3. © Eastbourne Coroner's Office
The Coroner
Independent judicial office holder
Investigate deaths that are violent, unnatural, unknown or in police custody/state detention
Coroners and Justice Act 2009 and The Coroners Rules 2013
The Chief Coroner
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4. © Eastbourne Coroner's Office
The Chief Coroner
Collate, monitor and publish coroners’ reports to authorities to prevent other deaths (PFD)
Allows delegation of administrative functions to Coroner’s Officers (investigation)
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5. SOME ROLES OF CORONER’S OFFICERS
Coroner’s “right-hand person”
Medical investigator
Forensic investigator
Coroner’s
Officer
Administrator
Jury arranger
Family liaison
Media relations
Counsellor and advisor
Statement taker
Court clerk
Police liaison
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© Mrs A Warner Coroner's Officer 2009

6. Deaths Coroners Officers Attend
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7. Investigation at scene
Gather relevant history/information for Coroner & Pathologist
Hands on!
Take photos
Statements
Seize exhibits
Give advice and support to Police officers
Immediate family contact
Continuity to mortuary
Pass information to other agencies, e.g., H&S Ex, Fire….
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8. © Eastbourne Coroner's Office
Type of Post Mortem
Coroner’s PM (to establish cause of death) Can be invasive or non invasive
Special PM (extended skills)
Forensic PM & 2nd PM’s
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© Mrs A Warner Coroner's Officer 2009

9. © Eastbourne Coroner's Office
Type of Inquest
Two types of Inquest:-
Jamieson (who, how, when & where)
Middleton (Article 2 of HRA includes ‘in what circumstances’)
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10. Suspension of Inquests
Homicide offence or equivalent
Prosecuting authority informs Coroner
IPCC
HSE
Accident Investigation Branch
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11. © Eastbourne Coroner's Office
Case Study 1
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12. Man dies in Hailsham tyre company incident
A man has died at a Sussex tyre supplies company in an "industrial incident", police have said.
The 54-year-old was killed on Monday at about 1400 GMT while transporting heavy equipment.
The man was pronounced dead at the scene. A post-mortem examination is due to take place on Wednesday.
Sussex Police said it was working with the Health and Safety Executive to establish what happened.
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13. © Eastbourne Coroner's Office
Case Study 2
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14. © Eastbourne Coroner's Office
Case study 2/b
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15. © Eastbourne Coroner's Office
Case Study 2c
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16. © Eastbourne Coroner's Office
Case Study 2d
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17. © Eastbourne Coroner's Office
Outcome of the Inquest
Upon his death in 2010 an investigation was held by Sussex Police and the Health and Safety Executive. Apaseal as a company was fined for breaches of health and safety. That investigation came to a close in April 2014, allowing the inquest hearing to proceed in order to determine how Mr Parsons came by his death
The inquest heard how the skates had been a suitable choice of equipment to handle the weight of the machine in question but that after the worker’s death, one of the skates was found with its disc unattached next to the scene.
A jury of eight returned a unanimous verdict of misadventure.
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18. © Eastbourne Coroner's Office
Manslaughter?
A roofing firm boss has been jailed for 12 months for manslaughter due to gross negligence after a 20-year-old employee fell 20ft (6m) through a skylight.
During the 13-day hearing, the court heard Mr Hoofe did not have a harness and there was no safety net.
"wholly untrained to work at height," not supervised at the "critical time", and "provided with inadequate and insufficient materials to do the work safely".
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19. © Eastbourne Coroner's Office
Conclusions
Accident or misadventure
Alcohol/Drug related
Industrial disease
Lawful/unlawful killing
Natural causes
Open
Road traffic collision
Suicide
Narrative
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20. England and Wales (Total)
Statistics
England and Wales (Total)
Total conclusions recorded
Accident and misadventure
Natural causes
Suicide
Drugs/Alcohol Related
Road Traffic Collision
Industrial diseases
Unclassified conclusions
Open
All other conclusions*
2005
26,814
9,498
6,175
3,235 .
2,567
1,952
2,531
856
2006
27,547
9,353
6,828
3,220
2,496
2,406
2,378
866
2007
27,360
8,930
7,011
3,007
2,332
2,923
2,242
915
2008
28,996
9,230
7,556
3,305
2,474
3,333
2,167
931
2009
29,781
8,673
8,281
3,330
2,623
3,797
2,240
837
2010
29,385
8,113
8,382
3,252
2,560
4,180
2,115
783
2011
29,858
7,775
8,818
3,471
2,569
4,400
2,117
708
2012
30,123
7,705
8,849
3,515
2,756
4,634
2,059
605
2013
31,579
8,166
8,881
3,754
2,766
5,343
1,920
749
2014
29,153
7,941
4,873
3,851
1,645
602
2,874
5,261
1,882
211
2015
35,473
7,977
11,043
3,899
2,267
779
2,733
4,870
1,736
169
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21. Reports to 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.
All reports and responses must be sent to the Chief Coroner. In most cases the Chief Coroner will publish the reports and responses on this website. Details of the procedures are set out in Regulations 28 and 29, Coroners (Investigations) Regulations 2013.
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22. Reports to Prevent Future Deaths
Clear, brief, focused, meaningful and wherever possible, designed to have practical effect
Can be made before or after Inquest hearing (urgent action required)
‘A PFD report is a recommendation that action should be taken, but not what that action should be’
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23. © Eastbourne Coroner's Office
PFD’s
Should be sent out within 10 working days of Inquest
Sent to the Person the Coroner believes may have the power to take such action
56 days to respond
Detail action to be taken or explain why no action proposed
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24. © Eastbourne Coroner's Office
If only?
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