Coroners are called to investigate sudden, unexpected and violent deaths. In the more complex cases, they open an inquest.
The BBC's social affairs correspondent Michael Buchanan has seen many coroners in action and reported from many inquests.
For this programme we follow the inquest of Daniel Lindsay, who died in 2023 aged 41 in a Surrey care home, as we ask wider questions about coroners courts in England and Wales. Are they operating as well as they could and are there ways they could be better?
We discuss claims the system is ‘chronically under-funded’, even 'broken'. We ask why there is such variation and inconsistency between different coroners – a so-called ‘postcode lottery'.
We hear from Daniel Lindsay’s cousins as we explore what it is like for a bereaved family to go through an inquest and ask whether the interests of relatives should be given a higher priority.
The Chief Coroner in England and Wales Alexia Durran responds to concerns and explains what she is doing to make the service more responsive and accountable.
Details of advice and support with bereavement, or end of life care are available at bbc.co.uk/actionline.
Producer: Leela Padmanabhan Sound design: Hal Haines