Our study1 of timelines in death investigations conducted by Australian coroners, published in this issue, suggests that lengthy delays have adverse consequences for public health. Delineating those consequences depends on a prior step: understanding the public health role of the modern coroner.

Coroners are public officials. General descriptions of their structure and functions are inherently difficult because, like the political-legal environments in which they are embedded, there is variation across and within countries. The USA has a particularly convoluted arrangement, with two divergent models of death investigation (coroner and medical examiner) located at multiple jurisdictional levels (city, county, district and state).2 ,3

Arrangements in the Commonwealth of Nations tend to be more homogenous. (Several Canadian provinces that have adopted a medical examiner model are notable exceptions.) Coroners are typically lawyers or doctors. They may operate from the judicial branch (as judges or magistrates) or from dedicated offices in the executive branch. Their primary function is to investigate the ‘who, how, when and where’ of unnatural and unexpected deaths. Deaths due to injury are normally categorised as unnatural, and thus reported to and investigated by coroners.