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The Coroner Role & Preparing for a Coroner’s Inquest Learning from Deaths

Learning from Deaths and implementing Coroner recommendations at a local level

The Coroner Role

Andrew Harris
Senior Coroner, London Inner South;
and Professor of Coronial Law
William Harvey Research Institute, Queen Mary’s University London

• notification of deaths to Coroner
• investigatory roles of Coroner
• what is unnatural death and opening an inquest
• Covid Deaths


We have to remember the stages of bereavement, we have to be mindful of the family during our investigation

Andrew Harris


Dr Martin Farrier
Clinical Director for Quality & Consultant Paediatrician
Wrightington, Wigan and Leigh NHS Foundation Trust

• the role of the Medical Examiner
• ensuring the appropriate direction of deaths to the coroner
• understanding the root cause of avoidable deaths, ensuring independent review and  correct referral to the coroner
• understanding which deaths are attributable to problems in care at a local level
• ensuring conclusions in investigations will lead to inform learning and change

A very interesting talk this morning from Dr Martin Farrier.  As an overview, Martin Farrier discussed Wrightington, Wigan and Leigh NHS Foundation Trust's experiences. 

During the talk, one of the key take homes was about how they provide learning to coroners, expressing that their has been a greater level of openness and clarity within the organisation. He discussed how frailty was one of the organisations dominant problems and how they are working to create effective ways to ensure reviews can help to prevent death.