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 Acting Senior Coroner is Paul Bennett. His jurisdiction covers the full extent of Pembrokeshire, Carmarthenshire and the coastal waters surrounding them.

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

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 Pembrokeshire Coroner's Officer employed by the police is PC James Lang - Telephone 01267 615310. Email james.lang@Dyfed-Powys.police.uk, Jerome Carlson - Telephone 01267 617351 / Email jerome.carlson@dyfed-powys.police.uk and Roger Smith - Telephone 01267 615795 / Email roger.smith@dyfed-powys.police.uk

The Carmarthenshire Coroner’s Officers employed by the police are Malcolm Thompson (Telephone 01267 615108 Email malcolm.thompson@Dyfed-Powys.police.uk) and Hayley Rogers (Telephone 01267 615 107 Email hayley.rogers@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 and 01437 775147

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^th 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

This Charter tells you what standards of performance are to be expected in the coroner service, and what to do if something goes wrong.

Legal Position

The Coroner Service operates within a legal framework. It is the duty of the coroners to investigate deaths which are reported to them and which appear to be due to violence or are unnatural, or are sudden and of unknown cause, or which occur in legal custody, and to carry out certain related responsibilities

Conduct

• The Coroner and his 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 the 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 purposes of the coroner's statutory responsibilities
• Confidentially 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.

Correspondence

 Written enquiries to the coroner will normally receive a reply within 10 working days of receipt. If the matter cannot be resolved within that time, an acknowledgement will be issued within 5 working days with an estimate of when a substantive reply will be sent.

Inquiries not requiring an inquest

If a death is reported which does not need to be the subject of an inquest a certificate giving the cause of death will be sent to the registrar of deaths within 5 working days of the completion of the coroner's enquiries

Before the Inquest

Interviews

If the coroner or his officer or staff need to interview someone about a death, the aim will be to do so no more than once, at at time and place convenient to the person concerned. If the person wishes, they may be accompanied during the interview by a relative, friend or other person. Every effort will be made to avoid causing any additional distress to close friends or relatives of the deceased. A copy of any statement to be used at the inquest will be provided to the person who made it, on request at least 5 working days in advance of the hearing (unless the coroner has good reason not to release it).

Post Mortems

When the coroner decides that a post mortem is necessary, wherever possible, the immediate next od kin whose details are known, will be given:

• If requested, an explantion why a post mortem is necessary and what is involved;
• Advance notice of the arrangements so that they may be represented (by a doctor) if they wish (but post mortem examinations must normally be undertaken as soon as possible, usually within 24 hours of the discovery of the death). Notice may not always be practical;
• If requested, a copy of the post mortem report

Administrative arrangements

The coroner will notify those asked to attend an inquest:

• The date and time if each hearing (if more than one) at least 8 working days in advance (but notw that the formal opening of the inquest - for taking evidence of identity and the medical cause of death - will generally take place within 2 days of the report of the death, at which point the body will normally be released);
• details of the location of the court where the inquest will be held;
• details of the telephone number for enquiries; and will:
• provide a leaflet explaining the purpose and procedures of inquests;
• advise those who express a wish to do so that they may attend an inquest as an observer beforehand;
• explain to those called as witness or juror how to claim for travel and subsistence expenses and for financial loss allowances;
• ascertain any preference for swearing evidence (e.g. in accordance with specified religious beliefs, or on affirmation)

Timing

The coroner will endeavour to hold any neccessary inquest at the earliest possible date. Most inquests take place within 6 months of the death. 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 of the position, including the reasons for any continuing delay, on a regular basis unless the inquest had been formally adjourned to a specific date.

Release of the body

The coroner will release the body of the deceased for the funeral at the earliest opportunity, normally within 3 days. Where there are uncertainties 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.

Disclosure of information

The coroner will, on request and at his discretion, provide to interested persons not less than 8 working days in advance of the request, copies of the post mortem report for which payment may be required 

Jurors

For jurors, the coroners will:

• send a leaflet explaining the duties of a juror at an inquest, and providing other relevant information, 10 days beforehand;
• 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 provided with a written explanation about how, where and when a copy of the death certificate may be obtained.
• If, in the interests of preventing further fatalities, the coroner decides to report the matter to a relevant person or authority, he will do so within 15 working days of the inquest outcome. He will also send copies of his letter to all the interested persons. A copy of any subsequent reply will be sent with 5 days of its receipt.
• The coroner will supply an interested person, on application, a copy of the inquest verdict (although this is reproduced on the death certificate), or any of the documents produced in evidence, within 10 working days of receipt of the prescribed fee (which will vary according to the number and size of the documents to be copied). An estimate of the fee will be provided in advance if requested.
• The coroner will also supply for the prescribed fee, a copy of his notes of evidence, but this may take up to 8 weeks to provide. In all cases, an estimate of the fee will be given on application
• The coroner/local authority will pay witness and juror expenses claims promptly and within 15 working days of receipt of properly completed applications

Applications for permission to remove a body abroad

The coroner will make every effort to complete his enquiries and decide such applications within 5 days of receipt of notice

Treasure inquests

Coroners have responsibility for enquiries into treasure finds. Information leaflets about treasure are available from the coroner's office.

Feedback and complaints

Coroners will not normally enter into correspondence about the cases they have completed, but comments and suggestions on improving the coroner service are always welcome. Please contact the coroner's office at the address given above. The aim of the coroner service is to provide a service of excellence so that you should have no cause for complaint, but if you do, the complaint will 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 procedure on request, but cannot give legal advice.
• All complaints about the administration of the coroner service, or the conduct of individual coroners or their staff, should be raised in the first instance with the coroner by writing to him or telephoning him at the contact point given in paragraph 7 The coroner will reply to such complaints in accordance with the timescales set out above.
• If the coroner fails to deal with the complaint satisfactorily, the complainant may refer it to the Home Office (Coroners Section), Room 972, 50 Queen Anne's Gate, London SW1H 9AT. Tel: 02072732888/3574. The Home Office has no disciplinary powers or power to award compensation but may, in appropriate cases, refer the complaint to the Lord Chancellor who is responsible for the discipline of coroners.

Performance

The coroner's and Council's performance will be monitored regularly against the standards detailed in this document

Further information

Further copies of this charter may be obtained from the coroner's office. General information is contained in the Home Office leaflet 'The Work of the Coroner' also available from the coroner's office

Copies of this charter in Welsh are available from the coroner's office

This charter was first issued on 01-08-02 and will be reviewed annually

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