Death investigation and coronial practices have undergone significant social, political and legal scrutiny in recent years. A wave of coronial reform has occurred across jurisdictions, including in the United Kingdom (UK), Australia, Canada and New Zealand, with a concomitant focus on the adequacy of death investigation law and policy. Taking key coronial developments in the UK and Australia as its starting point, this paper explores a legal jurisdiction undergoing immense legal and policy reform to illustrate why coronial law and practice is of increasing scholarly interest. It begins by tracing the contentious landscape of UK coronial law reform, which has also resonated internationally, thereafter examining key controversies that refocused attention on the value of the jurisdiction, before discussing contemporary coronial issues including, publicity, human rights and death prevention.

Lord Neuberger describes open justice as a procedural principle requiring that ‘what goes on in court and what a court decides is open to scrutiny’ (Neuberger, 2011). The prime rationale given for this principle is that it is a safety check on procedural fairness. Such a conception of open justice applies on only a superficial level in inquests into use-of-force deaths at the hands of the state. This paper examines the practice of, and rationales behind, opening up use-of-force deaths at the hands of the state to scrutiny through inquests. They suggest a primarily intrinsic rather than instrumental link between openness and inquests’ purposes, which requires a reframing of traditional conceptions of open justice in this context. It is further argued that recognition theory can provide the normative link between openness and justice in these circumstances – a link that is implicit in the term ‘open justice’ but rarely explored in inquests.

This paper examines the role of coroners in investigating and reporting on cases of death after police contact (DAPC) in England and Wales. It considers how Article 2 (the right to life) of the European Convention on Human Rights (ECHR) has affected coronial processes and practices. It argues that the effects of Article 2 represent an evolutionary shift in accountability processes surrounding cases of DAPC in England and Wales, but that this shift has in turn been mediated by aspects of institutional structure in the coronial system. It discusses how this shift demonstrates the dynamic relationship between the coronial system, state and society and how this has continued to evolve as a result of external demands.

This paper follows collegiality, demonstrating how, as a central value of medically trained coroners, it can shape the content of death investigations and certificates. Drawing on ethnographic evidence from a 16-month-long study of the Office of the Chief Coroner (OCC) of Ontario, Canada, I argue that collegiality is an instrument of trust that both affords investigators tremendous access to information, and severely limits the flow of that information into the public domain that the OCC serves. The paper focuses on in-care death investigations, which are those where the OCC's medically qualified coroners find themselves investigating the quality of care delivered by professional colleagues. I show how professional expertise, experience and collegial values often combine to see instances of poor or even incompetent care dealt with privately (rather than publicly) or referred up the medical (rather than public safety) hierarchy. The burden of my argument is that collegial deference to the autonomy and skills of other physicians tends to see coroners expurgate the death certificates they produce. These expurgations obscure competence issues from public view and reduce the accuracy of the certificates. I close with a discussion of the benefits and drawbacks of medically qualified death investigators, as well as potential adjustments to improve the accuracy of in-care death investigations and certifications.

This paper examines the coronial manual as a technique of occupying office in the nineteenth and twentieth centuries. The manual guided coroners in the performance of their duties, obligations and responsibilities. It was preoccupied with questions of technical knowledge, operational processes and administrative procedure. The language of office that characterised coronial treatises prior to the eighteenth century was gradually supplemented in the nineteenth century by the discourse of bureaucracy. This paper argues that the guidebook professionalised the office of coroner in Australia by setting out procedures, forms and rituals for assuming responsibility for the dead. It also provided advice to coroners for devoting themselves to a vocation in the public service. The paper thus traces historical shifts in the technology of the coronial manual in British colonies and examines how a bureaucratic logic of the coroner's office affected the way in which coroners pursued justice during the death investigation process.

The long history of suicide as a criminal offence still has a significant contemporary effect on how it is perceived, conceptualised and adjudged. This is particularly the case within countries where suicide is largely determined within a coronial system, such as Australia, the UK and the US. This paper details the outcomes of a study involving semi-structured interviews with coroners both in England and Australia, as well as observations at inquests. It focuses around the widely held contention that the suicide rates produced within these coronial systems are underestimations of anywhere between 15 to 50 per cent. The results of these interviews suggest that there are three main reasons for this systemic underestimation. The first reflects the legacy of suicide as a criminal offence, resulting in the highest standard of proof for findings of suicide in the UK, and a continuing stigma attached to families of the deceased. The second is the considerable pressure brought to bear upon coroners by the family of the deceased, who, because of that stigma, commonly agitate for any finding other than that of suicide. The third involves the rise of ‘therapeutic jurisprudence’, wherein coroners take on the responsibility of the emotional well-being of the grieving families, which in turn affects the likelihood of reaching a finding of suicide. The conclusions drawn by the paper are also twofold: first – with respect to the stigma of suicide – it will take a lot more than simple decriminalisation to change deeply held social perceptions within the community. Second, given that suicide prevention programmes and policies are based on such deeply questionable statistics, targeted changes to coronial legislation and practice would appear to be required.