The Coroners’ System of Law of Lagos State- An Overview, Challenges, and the Way Forward

Hon. Justice Lateefa Okunnu

Paper delivered at the Two-Day Training for Coroners on the Coroners’ System Law of Lagos State on Wednesday, 4th of August, 2021.

An Overview

The purpose and function of the Coroner’s Court, generally speaking, is to inquire into deaths that occurred in such circumstances as to require a  better understanding and better knowledge of the events around and  about that death.  

The inquiry – the inquest – seeks to ascertain and determine four key  questions: 

i. Who? 

ii. When? 

iii. How? 

iv. Where?  

Inquests are not set up to determine the matter of fault as regards the  death in question. Coroners do not ascribe fault to anyone. That is the  exclusive preserve of the regular courts. And so the fndings of a coroner  do not attach liability to any person or body/institution.  

Indeed, the court is a tribunal of inquiry and not a court of law in the  conventional sense of the word. By the governing law – the Coroners’  System Law of 2007 – it has, expressly defined for it, the ambit of its  jurisdiction as regards the types of deaths about which it is to inquire.  These are deaths that occurred in any of the circumstances set out in  sections 14 and 15 of the Law

And so, coroners inquire into “investigable deaths”, and conduct inquests  on deaths that occurred within their respective territories (“Coroner  Districts”) with a view to ascertaining the circumstances surrounding that  death.  

It is required, and indeed fundamental, that their verdicts include fndings  and recommendations for the consideration of the executive arm of  government. 

In this way, the coroner’s system plays an extremely vital role in our quest for good governance (most especially within the context of a developing  country) as it assists in the formulation of policies, and the introduction (or amendment or revision) of laws aimed at correcting certain mischiefs and ills that have come to be found to exist and which can lead to death in  largely avoidable (read: “investigable”) circumstances. For example:  

  • Death from being knocked down by a car at a particularly  cumbersome, very busy road junction; 
  • Death by drowning at a particular coastal location; 
  • Death at a factory and whilst in the course of work; 
  • Death resulting from the collapse of a building (or at a building  construction site); 
  • Death from an airplane crash; 
  • Death from a medical procedure; 
  • Death whilst in official custody. 

The coroner would seek to know the answer to the “four key  questions” for the sake of avoiding the recurrence of such a  tragedy in the future. That, in essence, is what the system is all  about. 

[Quaere]: Whether the argument of exceeding jurisdiction by investigating a death that has some bearing on matters in the Exclusive Legislative List  (for example, aviation) but which death occurred in one’s district and in  Lagos State is a valid one.] 

Coroners report to the Chief Coroner of Lagos State who, in turn, issues  reports on a periodic (quarterly) basis to the Attorney-General and  Commissioner for Justice of the State. The coroners’ reports are therefore  expected to be more regular than the Chief Coroner’s holistic quarterly  report to the State. 

It is of extreme importance to the realisation of the aim and purpose of  the Coroner’s Court that reporting obligations are fulflled, and that these  reporting obligations contain all the key elements for the attainment of  those objectives. 

Bearing in mind the fact that the Coroner’s Court is a “change agent” for  good governance, I expect that one would seek to elicit/deduce from the  reports the following, amongst other information: 

  • What led to the person’s death – that is, “How?” Not “Why?”; 
  • The preponderance of such deaths – in terms of location/locality,  number, manner, etc; 
  • Factors that led/contributed to the death; 
  • Events (including systemic and/or institutional ones) that could have prevented such deaths; 
  • A deliberate highlighting of acts of commission/omission with regard to the death, or the manner of death (without finding fault); 
  • Any such other indices that would aid/promote better development  by leading to a review/introduction of governmental policies, rules,  regulations, bye-laws, and primary laws. 

A well-developed coroner system will be a key factor in aid of good  governance in Lagos State. The point cannot be over-emphasised. This is  because its main purpose, as I see it, is to encourage better development, higher standards of care/skills, and also to promote the notion of  accountability by those who, by virtue of their respective functions, are  entrusted with a duty of care over others.  

In so doing, the coronial system is efectively geared towards: 

  1. introducing new legislation, or enforcing/improving upon existing  laws and regulations – for example road traffic or work place laws  and regulations;  
  2. forestalling/reducing acts of professional negligence; 
  3. promoting proper care and attention for the disadvantaged and the  weak – the poor, the aged, the homeless, the downtrodden – under  the banner of a Welfare State (c.f. Chapter II of the Constitution); 
  4. reducing instances of death by suicide, substance abuse, etc.; 
  5. forestalling/reducing acts of neglect (by omission and by  commission), and negligence by public officers/offices (the prisons,  health facilities, free ambulance services, town and physical  planners, engineers, lifeguards, etc.);  
  6. forestalling/reducing acts of misconduct by those ordinarily to be  held to account; 
  7. reducing extra-judicial killings and acts of torture/inhuman and  degrading treatment, and thus enforcing citizens’ fundamental  rights and improving the criminal justice administration system; 
  8. fine-tuning or implementing any and all subsidiary laws, rules and  regulations in the important area of health and safety (“H & S” – to  me, a key expression!); 
  9. generally promoting the enactment of new laws and the revision of  existing ones;  
  10. generally making recommendations geared towards the  formulation/implementation of government policy in relevant and  key areas of governance and development. 

I believe that it is in these that one finds the raison d’être of the  coronal system – it exists as a veritable fact-finding machinery  and tool for the promotion and development of good governance,  and the enforcement of higher standards of care all round. 


  • The main challenge is education – the lack of awareness,  understanding, and appreciation of the system. 
  • And so, people do not know about the existence of this avenue of  enforcing their right to better standards; of making governance  more efficient, more responsive, more accountable, and better developed for the sake of the people and the Common Good. This  lack of knowledge almost defeats the purpose! 
  • There are challenges on the matter of delay in burials because of  the requirement to conduct post-mortem examinations. 
  • There are challenges from the legal community who pay no heed to  the fact (or fail to understand) that an inquest is totally inquisitorial  in nature AND that it is no more than a fact-finding mission (purely  to answer the “four key questions”) with no powers to pronounce on liability or fault. And so, they seek to frustrate/truncate the process. 
  • There are challenges of an administrative type regarding a smooth,  seamless coordination of efforts between the Coroner’s Court and  the Police. 


1. A public enlightenment campaign and publicity drive as a first step – workshops, standardised information pamphlets, a dedicated website, and the likes.  

Such pamphlets should be readily available at reception/entrance areas of all court buildings, hospitals (public and private), local government offices, public libraries, police stations, correction facilities, interment service  companies; and at institutions that provide social welfare services such as the Lagos State’s Citizen’s Advice Bureau and the Office of the Public  Defender and their non-governmental counterparts. 

During a visit/tour to study the Coroner’s Court of England and Wales personally undertaken by me a while back, I made the following  observation about the pamphlet put out by the Court: 

… members of the public are well informed/guided on the coronal system via readily  available information (on the internet and in pamphlets) from the Ministry of Justice  and other governmental and non-governmental Institutions they learn about what an  inquest is, the purpose of one, the circumstances that will entail the holding of one, the  way and manner it is conducted, general enquiries they may have (“FAQS”), and their  respective roles (as bereaved family members, witnesses, etc.) preparatory to, and at,  such hearings … 

2. Getting the understanding and buy-in of key stakeholders who must  be counted on for their support always – that is, the Police, religious  institutions, traditional institutions, the Press, etc.  

The Chief Medical Examiner is already very much a part of the Coroner’s  system. The coroners in their respective districts must maintain a close  working relationship with his team in that district (the nearest General  Hospital) in order for all to perform optimally. 

On a continuation of my private tour, this time to Ontario, Canada, I noted the following: 

He [this is Dr. Bert Lauwers, the then Deputy Chief Coroner (Investigations of the  Coroner’s Court of Ontario] also explained to me that in order to alleviate the problem  of cultural and religious differences that result in opposition to inquests, the Coroner’s  Court of Ontario has a policy of first meeting one-on-one with the particular bereaved  family in order to explain to them the basis of the requirement that an inquest be held.  He said this approach has helped to reduce the incidence of misunderstandings,  mistrust, and friction, and has fostered active Cooperation towards a successful inquest.  In other words, effective communication is key to breaking down the barriers, and  promoting a proper understanding o the system  To this end, the coroner’s in Ontario  work with the aid of a particular manual (“Multifaith Information Manual”) which  explains the principles and ideologies of many of the different religions in the world.

3. The introduction of formal Rules of Procedure for the Coroner’s  Court so as to have a uniform, efficient and effective system of operation by which all are well-guided. (Mr. M. A. Etti, a coroner in Lagos State,  prepared a draft of one, purely at his own initiative, with valuable input  from Mr. Gbolahan Adeniran the present Attorney-General and  Commissioner for Justice of Ogun State who, at the time, was a special  adviser to the Governor of Lagos State, working with the Attorney-General of Lagos State) 

4. A strong administrative system with specialist personnel (Coroner’s  Court Registries, Coroner’s Officers to work under each district) to act as a backbone for the system. Again, I observed as follows during my visit to  some coroner’s courts in England: 

… each court has its own administrative officer, manned by personnel (known as the  “Coroner’s officers”) who even though employed by the Police, are answerable to the  coroner of the court! (I understand that the local governments are now to take over  from the Police as their employers). The role of the officers to build up the file of each case and to ensure that all the witnesses are contacted and the evidence relevant for an inquest is made ready for, and by, the date of hearing. To this end, they liaise with the  hospitals (pathologists, doctors, nurses), the family of the bereaved, the Police, and any  other persons that may be required to testify in each case. I noticed that these officers are in direct, regular contact with all these potential witnesses, gathering and garnering the relevant information preparatory to to holding of an inquest…

5. Training and continuous training of coroners (The fact of being  magistrates means that by orientation they may lean more towards an  adversarial, instead of an inquisitorial, approach to the work at hand. That impulse must be resisted with constant training, including a comparative  analysis with foreign jurisdictions so as to imbibe international best  practices). 

6. I would advocate a change in the law to allow members of other  relevant professions (perhaps retired academics and retired practitioners  in fields such as medicine, civil engineering and town/physical planning) to be coroners. The circumstance of the death in issue will determine which  coroner (amongst the team of varied professionals in that coronal district) would conduct the inquest because of his/her background qualifications and experience. Remember again, the Coroner’s Court is not, strictly speaking, a court of law in the conventional sense. 

7. Mandatory education about the Coroner’s Court as part of a Law  degree curriculum – both for the undergraduate course and the  professional (Law School) programme. Indeed, there ought to be visits to  coroner’s courts by Law School students as a necessary part of their  practical training. Every lawyer must have good knowledge of the system, and a the understanding of the inquisitorial nature of the same.  Otherwise, coroners will continue to experience difficulty with lawyers who are unable to disabuse their minds of the fact that the coroner’s court is  not a regular “court” but rather a fact-finding tribunal of the inquisitorial  kind. And so, coroners must “descend into the arena”! This is another  observation from my London visit: 

… at hearings, coroners do spend tie asking witnesses deep, extensive, probing, and (I  dare say, intelligent questions geared towards establishing the cause of death – particularly in circumstances where the evidence given by the witness is of a technical nature. They seek to understand technical language that may be contained in a report or statement … 

Indeed, there is the other difficulty (common in the legal world in these  parts) of imagining that the coroner’s system is part of our criminal law  adjudication system! A most erroneous belief! The coroner system is  divorced from our criminal law system. That is why you don’t read about  the coronal system in Criminal Law textbooks. The Coroner’s Court,  rather, is geared towards assisting the executive arm of government in  reviewing laws and considering new ones in a bid to reduce the incidence  of death in a particular, identified circumstance. The legislature, of course, passes laws. And so, in effect, it showcases the synergy between the  three arms of government in their overriding duty to serve the people of  the State; to protect and enhance the welfare of citizens in line with the  policy statements and covenants set out in Chapter II of the  Constitution.  

8. This leads on nicely to another consideration of the coroner’s  reporting obligations. The significance of those reports cannot be  underestimated. They help to highlight the issue of the death in question – most especially, how it came about – with a view to taking steps (both at  the State and Local Government levels) aimed at preventing a recurrence  or reducing the incidence.  

In my respectful view, the periodic reports of the coroners to the Chief  Coroner form the bulwark of the Chief Coroner’s report, in turn, to the  Attorney-General and Commissioner for Justice. In preparing a uniform format for the use of coroners, I think that we would want to deduce the  following, amongst other matters: 

A. With respect to “investigable deaths” that come to the coroner’s  attention –  

– the date of their enquiry to the Police/hospital/prisons, etc.; 

– the response or non-response of the Police, etc. (including any follow-up action on the coroner’s part); 

– the total number of investigable deaths during the period in  question; 

– the total number of enquiries they made. 

B. With respect to requests made to coroners for inquests to be conducted –  

– the person/office/body that made the request; 

– the date of the request; 

– the number of requests; 

– the date the inquest was opened; 

– the progress of the inquest where on-going (e.g., dates of  adjournments, number of witnesses); 

– the duration of the inquest (where completed); 

– a copy of their verdicts on completed inquests; 

– the number of inquests in their respective portfolios (both at  the beginning of the period of the report and at the end of  that period). 

There should be employed, and as part of the administrative system,  qualifed Data Analysts who, sitting with coroners’ reports, can assist the  Chief Coroner in highlighting key issues and making recommendations to  the Attorney-General on the emerging scenario from the investigated  deaths. To hone the point (and I conclude on this note) I learnt from Dr. Lauwers of Ontario, Canada that when it came to be known after a  number of inquests that a particular class of people had the highest  preponderance of death by drowning in the locality, the government was  made to understand from the Chief Coroner’s report that this class of  people (immigrants) did not know how to swim unlike the average  Canadian who learnt early in primary school. A law then came to be  enacted making it mandatory for immigrants to be taught to swim upon  “landing” in Ontario, Canada as part of their immediate cultural  immersion programme. 

I hope with this presentation, I has been able to highlight salient issues  concerning the Coroner’s System and thus opened up the space for  further discussions on how best to operate the same. 

I thank you for your kind attention. 

Lateefa Abisola Okunnu 



Leave a Reply

Your email address will not be published.