Chief Coroners Report 2016 A Brief Summary

The Chief Coroner is particularly pleased to report that the number of cases not completed or discontinued within 12 months has greatly reduced. The Chief Coroner has a statutory duty to report to the Lord Chancellor on these cases. Backlogs of cases have substantially decreased, since the introduction in 2014 of a standard procedure for reporting to the Chief Coroner on cases over 12 months, there has been a decrease by 52% of cases outstanding. This is a reduction from 2,673 cases to 1,285 cases, a figure which is now little more than 0.5% of all deaths referred to coroners in England and Wales.

Two years ago seven coroner areas had over 100 cases over 12 months old (two of them had over 200 cases); now there are none. 96% of coroner areas now have 40 or fewer cases outstanding. And 43 areas have less than 10 cases outstanding.

There are two further positive trends.

  • 1) The average time of all cases from death to inquest completed has fallen considerably by 28.6% from 28 weeks to 20 weeks.
  • 2) The percentage of deaths in which coroners have required a post-mortem examination has fallen by 2% from 38% of all cases to 36%.

Both figures are to be welcomed, although with a note of caution. The figures will to some extent have been affected by cases involving Deprivation of Liberty Safeguards (DoLS). There were 7,183 reported DoLS cases last year. But in view of the fact that a post-mortem will rarely be required and the inquests should normally be completed within a week, the number of DoLS cases will undoubtedly have affected the national picture.

Overall figures of Deaths in England and Wales.

There are usually about 500,000 registered deaths in England and Wales every year. This figure is relatively constant, although higher in 2015 with 529,613 deaths following an exceptional (and not entirely explained) increase over the winter months. All deaths are registered with the local registrar of births and deaths in order to create a complete record of how people die. Most of these deaths are from natural causes, certified as such by a general practitioner or hospital doctor.

But in every case where it is not clear that the death is from natural causes it must be reported to the coroner.

45% of all registered deaths are reported to coroners.

This amounts to some 220,000 or so deaths in England and Wales each year, higher than usual in 2015 with 236,406 referrals. But only a small proportion will require full investigation with an inquest. The vast majority of cases reported to the coroner are signed off by the coroner after preliminary inquiries, with or without a post-mortem examination, as being deaths from natural causes. A formal investigation under the 2009 Act is not required and therefore there is no inquest. Only a relatively small number of cases, therefore, require investigation and inquest. This figure is rightly reducing over the years, although the figure this year has increased from 29,153 inquests to 35,473 as a result of DoLS cases which accounted for over 7,000 inquests in 2015. This total number of inquests is still only 15% of all deaths reported to the coroner.

Nevertheless, the number of hearings is very much higher than any other comparable jurisdiction, and as the Chief Coroner recommends, they could be substantially reduced by a special procedure for non-contentious cases.

In the last year there have been only 457 jury inquests, many of which will have concerned deaths in prison or police custody under section 7 of the 2009 Act. In this context it must be noted that official statistics show that levels of self-inflicted deaths in custody continue to rise, especially amongst those recently admitted to prison. Coroners investigate all of these cases thoroughly and often make reports to prevent future deaths. The Chief Coroner held a one-day training conference for coroners in May 2015 on deaths in prison. He continues to sit on the Ministerial Board on Deaths in Custody and he sits on the majority of High Court cases arising from inquests into the deaths of prisoners. The issue is of continuing concern.

To read the full report of the Cheif Coroner, go here.  There is much more in it.