Sudden/Unnatural Deaths & Inquests SO CR 13 PDF

1 **SUDDEN/UNNATURAL DEATHS AND INQUESTS** **TABLE OF DOCUMENT DETAILS** Title Sudden/Unnatural Deaths and Inquests ------------------------------------ ----------------------------------------------- **Reference No** SO CR 13 St. Group/D...

1 **SUDDEN/UNNATURAL DEATHS AND INQUESTS** **TABLE OF DOCUMENT DETAILS** Title Sudden/Unnatural Deaths and Inquests ------------------------------------ ----------------------------------------------- **Reference No** SO CR 13 St. Group/Department Crime Steering Group Document Author PI 268 Vassiliou Approval by Chief Constable Approval Date May 2020 **Implementation Date** May 2020 **To be Reviewed Date** May 2023 **Last Revised Date** February 2020 **Quality Assured by** **Policy Department (PD) HQ** **Protective Marking** **Not Protectively marked** **Linked to other Standing Order** **Relevant Legislation** Coroners (Consolodation) Ordinance 21 of 1989 **Pages** 12 [Introduction](#Section1) [Page 3](#S1) [Section 1](#Section1) ------------------------------------------------------------------- ------------------ ------------------------ [Inquests](#Section2) [Page 3](#S2) [Section 2](#Section2) [Notes for guidance of Coroner's Officers](#Section3) [Page 3-6](#S3) [Section 3](#Section3) [Initial Action & Compilation of Inquests Files](#Section4) [Page 6-7](#S4) [Section 4](#Section4) [Sudden/Unnatural Deaths of Persons in Police Custody](#Section5) [Page 7-8](#S5) [Section 5](#Section5) [Compilation of Inquest Files](#Section6) [Page 8-9](#S6) [Section 6](#Section6) [List of Coroner's Officers](#Section7) [Page 9](#S7) [Section 7](#Section7) [Sudden Death and Access to Mortuary Procedure Guide](#Section8) [Page 9-12](#S8) [Section 8](#Section8) **TABLE OF CONTENTS** []{#Section1.anchor}**1.** **Introduction** The purpose of this order is to provide guidance to members of the Service and in particular to appointed Coroner's Officers and investigating officers regarding the action to be taken when a sudden or unnatural death occurs in the Sovereign Base Areas. []{#Section2.anchor}**2. Inquests** An inquest is a judicial enquiry seeking to establish the circumstances that led to and the cause of a sudden or unnatural death. []{#Section3.anchor}**3. Notes for guidance of Coroner's Officers** 3.1 A Coroner is a person empowered to hold inquests (Sect. 2). 3.2 Every Judge, or any other fit person empowered by the Administrator by Notice in the Gazette (including acting appointees) may hold inquests. However the Resident Judge shall hold all inquests unless prevented from doing so with reasonable dispatch. Nevertheless, other authorised persons may attend to procedures under the Ordinance in cases of urgency and/or in the absence of the Resident Judge (Sect. 3). 3.3 The Coroner's jurisdiction and duty to hold an inquest principally arises when "the body of the deceased person is lying within the Areas" and "there is reasonable cause to suspect that such person has died either a violent or unnatural death or had died a sudden death of which the cause is unknown" (Sect. 4) AND when a person dies in military or police custody from any cause whatsoever (Sect. 7). 3.4 When a body is found or a person has died, in such circumstances, any person finding the body or becoming aware of the death is under a duty to forthwith inform the Officer-in-charge of an SBA Police Station. That Police Officer, if not an authorised Coroner's Officer, shall notify an authorised officer as soon as practicable and, in any case, the authorised police officer shall as soon as practicable notify the Coroner (Sect. 10) using the notification *form* as shown on Annex 1. 3.5 The Chief Constable may, after consultation with the Senior Judge, appoint any other police officer not below the rank of Inspector to act as an authorised officer (Sect. 11). 3.6 An authorised police officer shall (Sect. 11). \(i) Inform the Coroner of known particulars concerning the cause of death and giving an opinion as to whether or not the death was due to any unlawful act or omission. \(ii) View the body and authorise its interment where death is believed not be due to any unlawful act or omission, but in all other cases cause the body to be taken to the Akrotiri Mortuary or the holding facility in Dhekelia. \(iii) Act as Coroner's Officer \(iv) Attend all inquests \(vi) Assist the Coroner in the manner in which Coroner's Officers by law or custom assist Coroners in England. (This would include such matters as searching for relevant evidence, interviewing potential witnesses, liaising with next of kin and other interested parties, reporting to and receiving instructions from the Coroner, serving witness summonses for the inquest hearing and organizing the actual sitting of the Coroner's Court). 3.7 The Coroner, upon receiving the report of a death from the authorised Coroner's Officer, will sign an order for post-mortem examination of the body "by any medical practitioner" or pathologist if that is considered necessary for investigating the circumstances of the death (Sec 12). The medical practitioner is the person with whom the SBAP has a contract at the time and he/she is responsible for dealing with all cases whether they involve local Cypriots or British service personnel. A copy of the form of order prescribed in the First Schedule of the Ordinance is attached as Annex 2 for reference. **3.8** After the post-mortem examination has been completed, the Pathologist will prepare the relevant cause of death form and the Coroner's Officer should endeavour to have the that report delivered to the Coroner or, at least, obtain brief details of the pathologist's findings and confirmation that the body can be released. This information should be communicated to the Coroner. **3.9** The Coroner has an overriding right to possession of the body for the purpose of inquiry into the death (R v Bristol Coroner ex-p Kerr \[1974\] QB 652). Subject to that, it is the personal representatives of the deceased who have the right to the body and, in default, the family members. (Williams v Williams (1882) 20 Ch, D 659; Hunter v Hunter (1930) 65 O.L.R. 586). **3.10** At any time after the body has been viewed the Coroner may make an order authorising the burial or other disposal of that body (Sec 15). That should not be done until the pathologist has completed the post-mortem examination and confirmed that the body will not be required for any further purpose. The Coroner has no power to authorise burial in another jurisdiction. The practice is therefore to make either an order for burial within the Sovereign Base Areas or an order for removal of the body out of the Sovereign Base Areas. No forms of order are prescribed therefore specimen forms as per Annexes 3 and 4 are to be used for this purpose. 3.11 The pathologist is required to make a formal report of the post-mortem examination to the Coroner in writing stating the conclusions drawn touching the death of the deceased and the cause of death (Sect. 13). The form of report prescribed in the First Schedule to the Ordinance is attached for reference as Annex 5 but more comprehensive reports are preferred. 3.12 The Coroner's Officer should ensure that the pathologist's written post-mortem report is furnished to the Coroner immediately it becomes available. At the same time or subsequently the Coroner's Officer may furnish his own report to the Coroner if it is believed that there may be reasons for dispensing with or deferring the holding of an inquest or further investigation into the death under Sections 4 and 5 of the Ordinance. For instance, if the death was due to natural causes, if criminal proceedings in request of the death have or are to be instituted, if the death was apparently not caused by any act or omission within the Areas or if an inquest or military enquiry into the death is to be held in another country or territory outside the Areas. The Coroner may make an order appropriate for the particular circumstances. If the Coroner is satisfied that an inquest is unnecessary, he has a duty under Section 26 (3) of the Births and Deaths Registration Ordinance 1975 to send a certificate to the Registrar stating the cause of death as disclosed by the post-mortem examination. 3.13 In practice all sudden or violent deaths are investigated by the SBA Police. The Coroner's Officer keeps the Coroner informed of the progress and result of the investigation. In due course the Coroner's Officer makes a report to the Coroner and furnishes the Coroner with copies of witness statements and reports appropriate for an inquest. The Coroner considers these papers and may request further statements or inquiries. 3.14 If the Coroner decides to hold an inquest, he advices the Coroner's Officer of the witnesses and reports that will be required. The original signed copies of those witnesses' statements and reports (together with English translations where necessary) are then supplied to the Coroner. 3.15 The Registrar fixes a date for hearing of the inquest in consultation with the Coroner and Coroner's Officer. The Coroner's Officer informs the next of kin of the deceased and any other interested parties of the date of the inquest. The Coroner's Officer reports to the Coroner advising whether any next of kin or interested parties are likely to attend or be represented at the inquest. The Coroner may issue summonses for the attendance of any witnesses if that is considered appropriate. 3.16 The following procedure is prescribed in Part IV of the Ordinance for every inquest: \(i) At or before the first sitting of an inquest the Coroner shall view the body or satisfy himself/herself that, it has been viewed by a police officer, medical practitioner or local authority (Sect. 15). \(ii) The Coroner has the power to summon and compel attendance of witnesses (Sect.16) \(iii) The Coroner's Officer shall attend the inquest (Sect.11) \(iv) The Coroner shall take evidence on oath but may admit documentary evidence if it is unlikely to be disputed or the witness is unlikely to attend or is unable to give oral evidence (Sect.14) \(v) Every interested party may appear in person or by advocate and examine, cross-examine or re-examine any witness (Sect.14) \(vi) The Coroner shall not be bound by the rules of evidence but a witness may object to answering any question that would tend to incriminate him/her (Sect. 17) \(vii) The Coroner shall take down in writing the minutes of the proceedings and notes of evidence but may direct that they be taken in shorthand and transcribed as the record of the inquest (Sect.18) \(viii) The Coroner may adjourn the inquest (Sect. 21) \(ix) After hearing the evidence the Coroner shall give his/her verdict (Sect. 24) and complete on Inquisition form as prescribed in Form D of the Ordinance (copy attached for reference as Annex 6) 3.17 Under Section 28 of the Ordinance and Section 26 (1) of the Births and Deaths Registration Ordinance 1975, within five days after the verdict is delivered, the Coroner shall send a certificate to the "registration authority"/ "Registrar" giving particulars of the inquest and findings made. The Area Officers for Akrotiri and Dhekelia are the Superintendent Registrars under the Births and Deaths Registration Ordinance 1975 for their respective areas. []{#Section4.anchor}**4. Initial Action & Compilation of Inquests Files** [Initial Action ] 4.1 It is not possible to give every action to be followed in cases of sudden/unnatural deaths but the Police must take action as shown below. a\. Obtain particulars of informer and visit the scene immediately. (If possible visit the scene with the informer - avoid contamination) b\. Commence a log of events. c\. The Coroner's Officer must be informed without delay and given the details obtained as described in para "k" below. d\. Treat all sudden/unnatural deaths as possible murders until proved otherwise. (Refer to [SO CR 1](https://modgovuk.sharepoint.com/:w:/r/teams/25468/STANDING%20ORDERS%202023/Standing%20Orders%202023%20onward/CRIME%20INTELLIGENCE%20SAFEGUARDING/CRIME/CR%201.docx?d=w350011853bab4f1fbf46f9f09b665858&csf=1&web=1&e=I3dfYk) and C2) e\. Call a doctor to the scene. (A person is not dead until certified dead by a doctor). f\. Once a person has been certified dead, the body **must** not be removed out of the jurisdiction of the Coroner's area in which it is lying. Once the SOCO has completed his/her examination and/or an autopsy carried out when required, the body will be conveyed to the Akrotiri mortuary under Police escort. g\. In cases where it is suspected that the death was due to an unlawful act or omission, the S.I.O. to call the state pathologist to visit the scene and carry out an autopsy. h\. Preserve the scene and call a SOCO for exhibits/photographs. i\. Preserve the body (in case of extreme hot weather or rain) without destroying evidence. If in doubt get advice from SOCO if not already at the scene. j\. Consider appointing a family liaison officer. k\. Obtain the following details and submit them to the Coroner's Officer without delay. - Name, address, occupation, nationality, age and gender of the deceased (in case of a child under the age of 12 months obtain date of birth) - A statement of identity from a close relative of the deceased - Circumstances in which the body was found including place, time and date - Name and address of the person who first found the deceased - Any known particulars concerning the death - Any medical history of the deceased l\. Upon conclusion of the examination of the scene by SOCO/pathologist, ensure that the body is taken to the mortuary within the Areas under Police escort. m\. Avoid disclosure of information to the media. []{#Section5.anchor}**5. Sudden/Unnatural Deaths of Persons in Police Custody** 5.1 Whenever any prisoner or person under punishment in military custody or any person in police custody either civil or military, shall die from any cause whatsoever, a Coroner shall hold an inquest. 5.2 When a body is found or a person has died, in such circumstances, any person finding the body or becoming aware of the death is under a duty to forthwith inform the Officer-in-charge of an SBA Police Station. That Police Officer, if not an authorised Coroner's Officer, shall notify an authorised officer as soon as practicable and, in any case, the authorised police officer shall as soon as practicable notify the Coroner using the nominated notification form. An investigation in the form of an inquest shall commence with the purpose of inquiring into, and reaching a verdict upon, the cause of and, to an extent determined by the circumstances behind the death, the reasons for the death. 5.3 The authorised police officer shall allow a criminal investigation to be instigated if necessary, by which the SBAP, in accordance with the duty imposed by the Police Ordinance, will investigate any, suspected criminal offence related to the death. 5.4 The authorised officer shall inform the AGLA, so as to afford an opportunity for the AGLA to discharge his statutory responsibilities if necessary. 5.5 The authorised officer shall inform the Chief Officer so that an internal investigation can be commissioned in accordance with the procedure as set out in OP30. The main purpose of this investigation will be to examine the systems and decisions within the prison service or custody suite, with the main aim of improving current practice, if appropriate. []{#Section6.anchor}**6. Compilation of Inquest Files** 6.1 The preparation of an inquest file varies slightly from the preparation of an average criminal docket. The inquest file must (a docket No. 1) contain an index, which will be placed on the very top of all other papers (on page 3), so that it is the first document encountered when perusing the file. It must be noted by investigating officers that every single sheet of the documents included in inquest files must be given serial numbers and **not** blue numbers. There is no need to divide an inquest file into sections. As a general rule the sequence in which documents will be placed in an inquest file will be as follows: a\. The summary report based on documents included **ONLY** in the inquest file b\. Statements/documents placed in chronological order of events starting from the top c\. The pathologist reports and any sketch plan, photograph to be attached on the statement of the witnesses providing them. The following index maybe used for guidance when preparing an inquest file: 1\. Summary Report of PC 300 SOTIRIS of SBA Police Page 1-4 2\. Statement of Yiannis Costi of (address) Page 5-6 3\. Statement of Andreas Georghiou of (address) Page 7-8 4\. Statement of Dr. Smith Page 9-10 5\. Statement of PC 400 KYRIAKOU of SBA Police and sketch plan Page 11-14 6\. Statement and post-mortem report of Dr. Sofoclis Page 15-20 Sofocleous 7\. Statement of PC 900 LOIZOU and photographic Page 21-42 supplement 6.2 An inquest file must be put together from original documents already included in the investigation file of the case/incident, once the investigation and criminal proceedings (if applicable) have been completed. Such documents must be those obtained during the investigation, that established the circumstances that led to and the cause of a sudden or unnatural death. 6.3 There will be no need for inquest files, processed for the Coroner's view, to be completed and then submitted for translation and typing. It is therefore recommended that when a document is received it must be immediately submitted for translation and typing. In cases of incidents involving criminal cases and inquests, it is the former that takes priority in terms of quick court presentation. The investigating officer must then submit through his/her first line manager the inquest file along with 2 true copies (which must contain typed documents) to the CID Inspector or any other appointed Coroner's Officer. The appointed Coroner's Officers are shown on Annex 7. All correspondence between the Coroner's Officers and the Coroner must be copied to the CJU Inspector so that the control register and Inquest File is kept up-dated for both divisions. []{#S7.anchor}**7**[]{#Section7.anchor}**. List of Coroner's Officers** Chief Superintendent Divisional Commander ESBA Chief Superintendent Divisional Commander WSBA Superintendent (Admin and Support) ESBA Superintendent (Admin and Support) WSBA Chief Inspector (Operations and Crime) ESBA Chief Inspector (Operations and Crime) WSBA CID Inspector ESBA CID Inspector WSBA **8**[]{#Section8.anchor}**. Sudden Death and Access to Mortuary Procedure Guide** 1. Whenever we are informed of a sudden death the following initial action is to be taken by the Police Teams; - Having informed the relevant emergency agencies, the Supervisor on duty will attend the scene and take control. (Incident log books should be started at the scene and the police station.) - The scene should be cordoned off immediately (Crime Scene Management) and traffic or other obstacles should be diverted away from the scene. - - - - - - - - 2. It is to be noted that the availability of Coroners change during the year therefore all information regarding the Coroner on call and his contact details will be available to all officers well in advance by the Criminal Justice Unit Sergeant. 3. The Forensic Pathologist Chara Spiliopoulou will be informed immediately regarding her requirement and once she has confirmed the date and time of her arrival or that of her assistant Dr Emannouil Sakeliades, on Island, arrangements are to be made to pick them up and convey her/him to the scene for autopsy or to RAF Akrotiri mortuary for the PME. 4. In the meantime the relevant **Order for Post Mortem Examination form** will be taken to the Coroner and signed by him/her. It is then to be handed over to the Forensic Pathologist. A SOCO and a member of the family will need to be at the mortuary. The appointed Family Liaison Officer will liaise with the family on this. 5. The family member will identify the body to the Forensic Pathologist whilst SOCO will assist in the taking of photos and seizure of exhibits requiring toxicological and histological examination. 6. Upon completion of the PME the Forensic Pathologist will prepare the relevant **Cause of Death Form** which will be taken to the Coroner who having been satisfied that he can release the body to the family will do so, by signing an **Order for the Removal /or Burial of the Body** form. 7. The body will then be handed over to the family who will require obtaining a death certificate from the Area Office, if the deceased is a local or a foreign national. As for UK Based Civilians and servicemen, death certificates are issued by J1. The FLO is to assist on these proceedings. 8. The initial actions and the investigation of Sudden deaths, whereby no foul play is suspected, is to be investigated solely by the Response Teams. Sudden deaths raising the suspicion of criminal activity or unexplained causes of death will be investigated by the Criminal Investigation department, thus the D.I and D.S should be informed immediately. 9. In the event that a deceased is of UK origin directly or indirectly connected to the SBA's, SIB to be informed. If out of office hours they can be contacted on 99-359283. 8.10 If at any stage, the family wishes to view the body whilst at the mortuary, arrangements are to be made with Othellos funeral services for the body to be clean prior viewing. This is part of their contract that upon completion of a PME they are to clean both the mortuary and the body for viewing purposes. **[Procedures for Access into Mortuary]** 11. As you are all aware the primary mortuary facility for the SBA is the Mortuary within RAF Akrotiri. The mortuary facility in Dhekelia was downgraded to a body holding facility. In the event of a sudden death at DKL, every effort should be made for the body to be transferred to AKR at the earliest opportunity. 12. The keys to the mortuary are kept at the M1 police station. It is kept in the security cabinet and will be handed over to police officers upon signature. A handing over mortuary key register has been introduced and is kept in the security cabinet at the control room. It is the responsibility of the Duty Sgt to handle the movement of the key upon signature. Upon completion of duties at the mortuary the key must immediately be returned to the Duty Sgt and signed back in. 13. Furthermore a laminated sheet with the Code to the inner mortuary premises can be found in the kitchen draws of the mortuary as one enters the mortuary premises. This is to remain there at all times. 14. A body is considered to be an exhibit. Whenever a body is removed prior the disposal authority, it should be escorted by a police officer. The escorting officer is to maintain a full written record for the purposes of continuity and identification procedures at any subsequent Coroner's Court hearing. 15. As soon as a body has been placed in the mortuary at Raf Akrotiri the SBAP Duty Officer is to notify the SBAA Duty Officer on Call (tel no. 99232781). It will be the responsibility of the Duty Inspector/Sergeant to notify the SBAA Duty Officer on call when a body is removed away from the mortuary. It will then become the responsibility of the CJU Sgt to keep the SBAA up to date with Coronial aspects. 16. When dealing with any sudden death, SBAP need to be aware of the family and community expectations, whilst at the same time fulfilling the investigative requirements for the Coroner's Court. Therefore, it is essential that the deceased is treated with respect and dignity at all times. It will be for the investigating officer to liaise with next of kin and relatives to explain the procedures and assist them through this difficult time.