The coroner service is one of the oldest public services in existence with the earliest references going back to the twelfth century. While always connected in some way with sudden or unnatural death, the complexity and importance of the modern coroner bears little relationship to his historical predecessor. Today’s coroner has a very wide range of duties involving investigatory, administrative, judicial, preventative and educational functions. Operating as an independent judicial officer, he1 must establish the ‘who, when, where and how’ of unexplained death. Contrary to common public perception, the coroner is not permitted to consider civil or criminal liability let alone to determine such matters. He must simply establish facts. In other words, his court is inquisitorial rather than adversarial – a critical distinction when examining many of the issues in this Report.