Coroner's Office

Coroner's Office

HM Coroner is an independent judicial officer holding office under the Crown. Every coroner is local to a jurisdiction, funded by the local council, but independent of Council, police, hospitals and Welsh Government.

The Coroner carries out investigations and establishes the circumstances and causes of death for the benefit of:

• the bereaved, who wish to know how their family member came to die (the circumstances) and how those circumstances came about (the causes)
• medical science, so that lessons can be learned from the circumstances and causes to advance medical care and to avoid future errors
• the public, who wish to be assured that the unexplained or violent death of one of its members is properly investigated in a manner that respects the need of the bereaved and of medical science

Remote hearings in the Coroner's Court: Guide for media and the public

Coroner

The Senior Coroner is Gareth Lewis. His jurisdiction covers the full extent of Pembrokeshire, Carmarthenshire and the coastal waters surrounding them.

When Mr Lewis is not available, his work is carried out by Assistant Coroner, Paul Bennett.

Mark Layton will also occasionally provide support within the jurisdiction as an Assistant Coroner.

Office staff

The administration of the coroner's office is carried out by the Clerks to the Coroner. The Clerks are normally the person first seen or spoken to when calling at or phoning the office. They have certain limited powers delegated to them by the Coroner and will be able to give information about the progress of an investigation.

The Clerks to the Coroner are: Ellie Jones, Belinda Smethurst, Amanda Edwards and Alison Millea.

Coroner’s Officers

Coroner’s Officers work under the direction of the Coroner to investigate the circumstances of the death referred to the Coroner and will deal directly with the family of the deceased. They are specifically trained to work with bereaved families and conduct enquiries on behalf of the Coroner. The Coroner’s Officers are employed by Dyfed Powys Police but work exclusively for the Coroner.

The Pembrokeshire Coroner's Officers are:

Jerome Carlson - Telephone 01267 617 351 / Email jerome.carlson@dyfed-powys.police.uk and

Roger Smith - Telephone 01267 615 795 / Email roger.smith@dyfed-powys.police.uk

They can also be contacted on coronerspembs@dyfed-powys.police.uk

The Carmarthenshire Coroner’s Officers are:

Hayley Rogers (Telephone 01267 615 107 Email hayley.rogers@dyfed-powys.police.uk),

Sarah Davies (Telephone 01267 615 172 Email sarah.davies2@dyfed-powys.police.uk), and

Rhiannon Griffiths (Telephone 01267 619 584 Email rhiannon.griffiths@dyfed-powys.police.uk)

They can also be contacted on coronerscarms@dyfed-powys.police.uk

Contact and enquiry points

The Coroner's office for Pembrokeshire and Carmarthenshire:  North Wing, County Hall, Haverfordwest, SA61 1TP. The office is open from 9:00am - 4:00pm, Monday to Friday

Telephone: 01437 775001, 01437 775134, 01437 775147 and 01437 776679

email: pembscarmscoroner@pembrokeshire.gov.uk

Out of office hours please contact police stations on Tel.101

If you are looking to use the tell us once service, please contact the registrar for your unique reference number.

Remote hearings in the Coroner's Court: Guide for media and the public

On the 28 June 2022, new regulations came into force giving effect to Section 85A of the Courts Act 2003. In brief these provisions allow the remote observation of proceedings in any court, tribunal or body exercising judicial function including, for the purposes of this guide, the Coroner’s Court.

As a result of the restrictions arising from the Covid 19 Pandemic, temporary arrangements were permitted whereby the press and the public could have access to live hearings using web based platforms such as Microsoft Teams and Zoom. In line with the principles of open justice this enabled reporting and observance of hearings to take place, subject to clear safeguards on non-participation in, nor recording of, the hearings themselves.

That arrangement has now been regularised by legislation and therefore the position to allow remote access to hearings by the media and public can continue.

However, the Chief Coroner has issued specific Guidance which sets out the basis upon which remote hearings are to be conducted and this includes the process by which members of the press and public should seek permission to attend remotely rather than in person.

While the right to attend an inquest in person will continue, the right to attend remotely will continue to be one that has to be the subject of permission. This Guide sets out the revised position.

In order to accommodate a request for remote attendance and in order to ease the administrative and technical arrangements, it will now be a requirement for anyone wishing to attend on a remote basis to make an application (in writing or by email) at least 24 hours before the hearing. It will no longer be the case that the office will deal with requests for a remote link on the morning of the hearing. This will not preclude the attendance of anyone who wishes to attend in person.

Any applications for remote attendance should be addressed to:-

The Coroner’s Clerk

Coroner’s Office

North Wing

County Hall

Haverfordwest

SA61 1TP

Or by email to: pembscarmscoroner@pembrokeshire.gov.uk

Useful links

Guide to Coroner Services (opens in a new tab)

Report a death to the coroner (opens in a new tab)

 

Coroner Charter

Pembrokeshire and Carmarthenshire Coroner Service Charter

 

Standards of performance and customer care 

 

Coroner Services: pembscarmscoroner@pembrokeshire.gov.uk

 

Application

This Charter tells you what standards of performance are to be expected from the Coroner Service, and what to do if something goes wrong. This Charter relates to the Coroner Service for Pembrokeshire and Carmarthenshire jurisdiction.

 

Pembrokeshire and Carmarthenshire Coroner Service best practice standards

• We will treat the bereaved and members of the public with consideration during the investigation process and inquest hearings. We will make available to the bereaved and the general public up to date and accurate information about the service we provide and how it can be accessed.
• We will investigate all sudden deaths, effectively, efficiently and impartially in accordance with the Coroners and Justice Act 2009. We will keep accurate up to date and understandable records of investigations and inquests. We will protect the confidentiality of information as far as possible within a system based on public court hearings. We will prepare for and respond effectively to major incidents.
• We will hold inquest hearings at an appropriate venue, and the hearing will be held in accordance with the Coroner and Justice Act 2009. We will carry out enquiries in accordance with the Treasure Act 1996.
• We will work in partnership with organisations, agencies and contractors in order to secure provision of the appropriate response to and investigation of sudden deaths.
• We will ensure that we will have enough investigative and administrative staff who are competent, knowledgeable, trained, supported to carry out the job effectively and efficiently.
• We will robustly assure and improve the quality of our work by monitoring, auditing, and reviewing our services, and through learning from the views, comments, compliments and complaints of the bereaved and other stakeholders.

 

 

Legal position

The Pembrokeshire and Carmarthenshire Coroner Service operates within a legal framework and complies with the Coroners and Justice Act 2009. It is the duty of Coroners to investigate deaths which are reported to them and where it appears that the deceased died a violent or unnatural death, the cause of death is unknown or the deceased died while in custody or state detention.

The coroner carries out certain related responsibilities and also investigates finds of possible treasure. In the jurisdiction of Pembrokeshire and Carmarthenshire one senior coroner is supported by two Assistant Coroners.

 

 

Conduct

Pembrokeshire and Carmarthenshire Coroners and Coroner Service staff will treat the bereaved and other members of the public courteously and sympathetically at all times, and will have regard, within the constraints of their statutory duties, to the deceased’s religious faith and cultural traditions.

Duties will be discharged impartially, with a view to ascertaining the facts surrounding a death for the purpose of the coroner’s statutory responsibilities.

Confidentiality will be preserved as far as possible within a system based on public court hearings. Explanations for the procedures adopted in particular cases will be given on request, where the coroner is satisfied that the person has a proper interest.

 

 

 

Correspondance

Written enquiries to the Coroner Service will normally receive a reply within ten working days of receipt. If the matter cannot be resolved within that time, an acknowledgement will be issued within five working days with an estimate of when a substantive reply will be sent.

 

 

Contact and enquiry points

The Pembrokeshire and Carmarthenshire Coroner Service is at:

 

North Wing, County Hall, Haverfordwest, Pembrokeshire

The office is open Monday to Friday from 9.00am until 4.00pm.

The telephone numbers are as follows:

General Enquiries 01437 775134, 01437 775001, 01437 775147, 01437 776679, alternatively via email to:

pembscarmscoroner@pembrokeshire.gov.uk

 

Inquests are usually held at either County Hall, Haverfordwest or Llanelli Town Hall, Llanelli, Carmarthenshire. In appropriate circumstances inquests may take place at an alternative venue. Those who are required to attend an inquest, or wish to do so, and have special needs are asked to contact the Coroner’s Office in advance.

Details of forthcoming inquests

 

Coroners and Coroner Service Staff will identify themselves by name in their dealings with members of the public. Assistant Coroners act when the Senior Coroner is not available. In doing so, they exercise the full powers of the Coroner.

 

 

Inquiries not requiring an inquest

If a death is referred which does not need to be the subject of an inquest, the coroner will either liaise with the Medical Examiner via a CN1a form or after a Postmortem has been carried out but there is a clear cause of death, the coroner will send the relevant Registrar a CN2 form so that the death may be registered.

 

Postmortems

When the Coroner decides that a postmortem – (autopsy) is necessary, wherever possible, the immediate next of kin, whose details are known, will be:

• Given an explanation as to why a postmortem is necessary and what will be involved
• After the postmortem has taken place, the Coroners’ Officer will contact the Next of Kin to explain the results and the next steps.

 

Release of the body

The coroner will release the body of the deceased for the funeral at the earliest opportunity. Where there is uncertainty as to the cause of death, or where the death is suspicious, it may be necessary to retain the body longer for further investigation.

The coroner will ensure that relatives are advised of potential delays and the reasons for them.

 

 

Deaths requiring an inquest

 

The investigation

Once the Coroner has opened an investigation, statements will be requested from relevant witnesses, this may include members of the family.

Our process can take some time but members of the family will be kept updated as to the progress of our investigation.

Members of the family can be provided with a copy of the postmortem report on written request and other relevant documents.

Members of the family will be informed that any retention of body tissue samples will be conducted in accordance with the Human Tissue Act 2004. (Full details are available from the Coroner’s Office).

 

The Inquest

The coroner will notify those who wish to attend an inquest of:

The date and time of the hearing(s). Please note that the formal opening of the inquest, for taking evidence of identity and the medical cause of death, will generally take place as soon as the coroner has received the pathologist’s initial postmortem findings.

For details of the location and facilities of the court where the inquest will be held please visit Inquests

 

 

 

Witnesses and Jurors

The Coroner Service will:

• Explain to those called as a witness or jurors how to claim for travel and subsistence expenses and for financial loss allowances within the permitted limits.
• Ascertain any preference for swearing evidence (e.g. in accordance with specified religious beliefs or on affirmation).
• Ascertain any special requirements for people who have special needs.

 

 

Timing

The coroner will endeavour to hold inquests as soon as possible. All inquest files are reviewed by the coroner on a regular basis to ensure that the investigation is progressing appropriately.

However, there may be factors outside the coroner’s control, which can cause delay. Where the inquest is likely to be delayed, the coroner will notify interested persons on a regular basis of the reason and the up to date position, unless the inquest has been formally adjourned to a specific date.

Details of forthcoming inquests

 

 

Disclosure of information

The coroner will, on request and at his discretion, provide to interested persons copies of the postmortem and other relevant evidence in advance of the inquest.

 

 

Jurors

For jurors, the coroner will:

• Liaise with them regarding timings, venue, parking and lunch provisions.
• Provide an indication in advance of how long the jury service will last.

 

After the inquest

On the conclusion of the inquest, the next of kin will be given information about how a death certificate may be obtained.

If the coroner’s duty under Regulation 28 (Prevention of Future Deaths) has been engaged, Interested Parties are entitled to a copy of the report and a reply on request.

The coroner may provide any document to any person who in the opinion of the coroner is a proper person to have possession of it. There may be a charge for providing the documents.

The proceedings at an inquest are digitally recorded. The coroner will supply to a properly interested person, on written request copies of the recording via a secure portal on which the proceedings have been recorded.

The Coroner Service will process witness and juror expenses claims promptly and within ten working days of receipt of properly completed applications.

 

 

Applications for permission to remove a body out of England and Wales

The coroner will make every effort to complete his enquiries and decide such applications within four working days of receipt of notice.

 

 

Support organisations

The Coroner Service has information and contact details for many support and counselling organisations. The Coroner’s Officer in the case at the inquest will assist in accessing this information.

 

 

Treasure inquests

Coroners have responsibility for enquiries into treasure finds. All enquiries into treasure are to be directed to the pembscarmscoroner@pembrokeshire.gov.uk

 

 

Feedback

Coroners will not normally enter into correspondence about the cases they have completed, but comments and suggestions on improving the Coroner Service are always welcomed.

To leave feedback about the service you received after attending an inquest, please write to:

 

Coroner Service

North Wing

County Hall

Haverfordwest

Pembrokeshire, SA61 1TP

 

Alternatively, you can contact the Coroner Service by emailing us at: pembscarmscoroner@pembrokeshire.gov.uk

 

Complaints

The aim of the Coroner Service is to provide a service of excellence so that everyone should be dealt with speedily and courteously.

Complaints about a Coroner’s decision or the outcome of an inquest can only be dealt with through the High Court. The Coroner’s Office will be able to explain the procedures on request but cannot give legal advice.

All complaints about the conduct of individual Coroners should be raised in the first instance with the coroner concerned by writing to Coroner Service, North Wing, County Hall, Haverfordwest, Pembrokeshire, SA61 1TP.

The coroner will reply within ten working days.

All complaints about the administration of the Pembrokeshire and Carmarthenshire Coroner Service or the conduct of Coroner’s Officers should be raised in the first instance with the Head of Coroner Service by emailing us at pembscarmscoroner@pembrokeshire.gov.uk.

Or by writing to The Coroner Service, Coroner Service, North Wing, County Hall, Haverfordwest, Pembrokeshire, SA61 1TP. A reply will be sent within ten working days.

Inquests

Deprivation of Liberty Safeguarding Orders (DoLS)

From Monday 3 April 2017 the Coroners and Justice Act 2009 was amended so that people subject to authorisations under the Deprivation of Liberty Safeguards (known as DoLS) will no longer be considered to be 'otherwise in state detention' for the purposes of Section 1 of the Coroners and Justice Act 2009.

The effect of this is that for any death that occurs on or after 3 April and where the deceased was subject to a DoLS authorisation the coroner will no longer have a duty to conduct an inquest in all cases. This change will also apply in other cases where the deceased their deprivation of liberty authorised through provisions in the Mental Capacity Act 2005. 

The change in the law will not apply to any death that occurred before Monday 3 April 2017 and inquests will still be required in those cases. Such deaths should be reported to the coroner in all cases even where the report is made after the 3rd April. 

For any person with a DoLS authorisation or other deprivation of liberty authorisation under the Mental Capacity Act 2005 who dies on the 3rd April, or any time after, their death need only be reported to the coroner where the cause of death is unknown or where there are concerns that the cause of death was unnatural or violent, including where there is any concern about the care given having contributed to the persons death.

 

Reportable Deaths Guidelines

Report a death to the Coroner

For medical professionals to report a death to the Coroner (opens in a new tab)

 

A death should be reported to the Coroner when a doctor knows or has reasonable cause to suspect that the death:

• Occurred as a result of poisoning, the use of a controlled drug, medicinal product, or toxic chemical;
• Occurred as a result of trauma, violence, or physical injury, whether inflicted intentionally or otherwise;
• Is related to any treatment or procedure of a medical or similar nature;
• Occurred as a result of self-harm (including a failure by the deceased person to preserve their own life), whether intentional or otherwise;
• Occurred as a result of an injury or disease received during, or attributable to, the course of the deceased person's work;
• Occurred as a result of a notifiable accident, poisoning or disease;
• Occurred as a result of neglect or failure of care by another person;
• Was otherwise unnatural.

The Coroner must also be informed where:

• The death occurred in custody or otherwise in state detention - of whatever cause;
• There was no attending practitioner or no-one is available within a reasonable period to prepare an MCCD;
• The identity of the deceased is unknown.

Frequently Asked Questions

Why is the coroner enquiring into a death?

A death can be reported to the Coroner for a number of reasons. The Coroner will then make enquiries into the death. Only a minority of deaths are reported to the coroner. In most cases, the deceased's own doctor or a hospital doctor is able to give a cause of death

Some examples of reasons for referring to the Coroner are:

• a doctor may not be sure of the cause of death or why the patient has died at an earlier date than predicted
• The death may have occurred in a manner that is not natural e.g. an overdose of drugs
• There may be violence associated with the death, either accidental, as in the case of a road death, or deliberate

 

Will there be an autopsy?

It is the coroner’s duty to find out the medical cause of death. On receiving a report, the coroner may decide that the death was natural and will authorise a doctor to sign a form stating, to the best of his information, what the medical cause of death was. Sometimes, although it is clear that the death was natural, there is not enough knowledge about the patient’s medical condition to say what the cause of death was. The coroner will then ask a pathologist to carry out, as soon as possible, an examination. If the examination, either known as an autopsy or as a post mortem examination (post mortem is Latin for “after death”) shows a medical cause of death and that cause was natural, there is seldom need for an inquest and the coroner will send a form to the Registrar of Deaths so that the death can be registered.

 

Will the funeral arrangements be delayed?

As soon as any autopsy has been completed and the medical cause of death known, the coroner notifies the Registrar of Deaths who will, if the death is natural, register the death and is able to issue a certificate authorising a burial. If a cremation is required, the coroner can issue a certificate authorising it. Even if the death is not natural so that an inquest has to be held, the coroner can, after formally opening and adjourning the inquest, issue either a burial or cremation certificate. These processes seldom take more than 48 hours, a period that is well within the normal period for arranging a funeral.

 

Can I register the death if an inquest is to be held?

Until the inquest has been completed, the Registrar of Deaths cannot issue a certificate as the conclusion of the inquest is not known. However the coroner issues an interim certificate of the fact of death, which enables progress to be made with the administration of the deceased’s affairs.

 

Why does it take such a long time between the inquest being opened and its conclusion?

Because full investigations take time, there may be a delay in completing the inquest. For example, a road death may involve taking statements from a number of witnesses, some of whom may not live locally. A report by an Accident Investigator may have to be prepared. An autopsy may not always reveal the cause of death and tissue samples may have to be examined at a laboratory. The tests and examinations can take 10 to 12 weeks or more. Whatever the reason for the delay, information regarding the inquest can be obtained either from this site or by way of direct communication from the coroner’s office.

 

Where can I get further help and information?

This list is not fully comprehensive so do not hesitate to get in touch with the coroner’s office for further information and help. Please remember that the office is only open from 9.00 a.m. to 4.00 p.m. Monday to Friday so if you phone outside these hours, the information that you seek may not be available. 

 

People we share data with

Unless a restriction is applied inquests are publically accessible and therefore data will be shared with anyone attending the proceedings, including the press.

During the course of undertaking their legal duties HM Coroner may at their discretion or as legally required share information with the following main organisations / individuals:

• City and County of Pembrokeshire and Carmarthenshire Councils
• Chief Coroner
• Dyfed Powys Police
• Pathologists and other medical professionals working for HM Coroner
• Funeral Directors in the area
• Local Coroners - specifically when cases are transferred to or received from
• NHS Hospital Trusts and other clinical / outreach bodies in the South Wales area
• Dyfed Powys Police and Crime Commissioner
• Ministry Of Justice
• Fire and Rescue Service for the South Wales area
• British Transport Police
• South Wales Ambulance Services
• Crown Prosecution Service
• Health and Safety Executive
• Care Inspectorate for Wales
• Families affected
• Register Office Staff in the South Wales area
• Cemeteries and Crematoria in the South Wales area