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1.10 H. M. Coroner


Coroners are independent judicial officers who are responsible for investigating violent, unnatural deaths or sudden deaths of unknown cause, and deaths in custody, which must be reported to them. All sudden or suspicious deaths must be reported to the Coroner, regardless of whether they have been raised under Safeguarding Adults.

The Coroner may have specific questions arising from the death of an adult at risk. These are likely to fall within one of the following categories:

  • Where there is an obvious and serious failing by one or more organisations;
  • Where there are no obvious failings, but the actions taken by organisations require further exploration/explanation;
  • Where a death has occurred and there are concerns for others in the same household or other setting (such as a care home); or
  • Deaths that fall outside the requirement to hold an inquest but follow-up enquiries/actions are identified by the Coroner or his or her officers;
  • In the above situations the Plymouth Safeguarding Adults Board should give serious consideration to instigating a Safeguarding Adults Review.

Any cases currently being progressed under Safeguarding Adults or where it is suspected that the Harm, Abuse or Neglect of an Adult at Risk has caused or contributed to their death must be raised with the Police and the Coroner.

All persons with relevant information should convey that information to the Coroner’s Officer, who will liaise with the Coroner. There is a duty to share information from a safeguarding adult’s process and investigation with the Coroner.

The Local Authority Adult Safeguarding Manager should be made aware of all enquiries from H.M. Coroner’s Office, received by the Local Authority or another agency, regarding a case involving adult safeguarding.

Local contact details:

H.M. Coroner’s Office
1 Derriford Park
Derriford Business Park
Derriford
Plymouth
PL6 5QZ

Main Office Tel: 01752 204636

Coroner’s Officers Tel: 01752 439679 or 439681

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