National statistics

Guide to coroners statistics

Updated 10 May 2024

1. Introduction

This document accompanies the annual Coroners Statistics bulletin and provides a background overview of coroners, focusing on concepts and definitions published in Ministry of Justice statistics. It also covers policy background and changes, statistical publication revision policies, data sources, quality and dissemination.

The annual Coroners Statistics bulletin presents statistics on deaths reported to coroners, post-mortem examinations and inquests held, and conclusions recorded at inquests in England and Wales. All editions of the bulletin can be found here: www.gov.uk/government/collections/coroners-and-burials-statistics. The bulletin also includes statistics on investigations regarding finds reported to coroners.

The Coroners Statistics are published annually in May and cover statistics for each calendar year. There is no scheduled revisions policy for this publication.

The United Kingdom Statistics Authority has designated these statistics as National Statistics, in accordance with the Statistics and Registration Service Act 2007 and signifying compliance with the Code of Practice for Official Statistics.

Designation can be broadly interpreted to mean that the statistics:

• meet identified user needs;
• are well explained and readily accessible;
• are produced according to sound methods, and
• are managed impartially and objectively in the public interest.

Once statistics have been designated as National Statistics it is a statutory requirement that the Code of Practice shall continue to be observed.

The data analysed in this publication are based on annual returns from coroners. Thanks are due to coroners and their staff for their work in preparing these returns.

Information on the quality and consistency of the Coroners statistics can be found in the supporting document published alongside this bulletin.

1.1 About the statistics

This annual bulletin presents statistics of deaths reported to coroners in England and Wales in 2023. Information is provided on the number of deaths reported to coroners, post-mortem examinations and inquests held, and conclusions recorded at inquests. The data are collected via statistical returns completed by coroners.

Inquests are usually opened in less than 20% of all deaths reported to coroners. In such cases, coroners are required to provide us with the conclusions of these inquests. The list of short form inquest conclusions which the coroners can provide is set out in legislation and can be found in Table 7 of the coroners’ publication.

Coroner services in England and Wales are governed by Part 1 of the Coroners and Justice Act 2009 (the 2009 Act), as well as the rules and regulations made under it. The 2009 Act came into force in July 2013, largely replacing the Coroners Act 1988^{[footnote 1]}.

The 2009 Act and its rules and regulations can be accessed via the links below:

www.legislation.gov.uk/ukpga/2009/25/contents www.legislation.gov.uk/2013?title=coroners

1.2 COVID-19 as a notifiable death and jury inquests

COVID-19 deaths are likely to be considered to be deaths from natural illness and, as such, will not be reported to coroners, apart from deaths which the coroner is under a statutory duty to investigate and/or hold an inquest (such as a death occuring in custody or another form of state detention, or where some aspect of the death, which may be independent of any naturally occurring illness, engages the coroner’s duty to investigate).

COVID-19 was classified as a notifiable death under the Health Protection (Notification) Regulations 2010 in March 2020. Notifiable in this context means notifiable to the public health authorities, not notifiable to the coroner for the purpose of death investigation (see above). Where the coroner has reason and decides to open an inquest into a death where COVID-19 is suspected to be the cause, section 7 of the 2009 Act (as amended) removes the requirement for the inquest to be held with a jury.

2. Data and Methodology

Coroners in England and Wales have continued to provide the data which is the basis of these statistics and proactively engaged with statisticians to ensure this report was produced in a timely manner and to high standards.

2.1 Related statistics

All deaths in England and Wales must be registered with the Registrar of Births and Deaths. For those deaths where a coroner conducts an inquest, the death will be registered at the conclusion of the inquest, and the cause of death classified according to the conclusion recorded by the coroner. Statistics on registered deaths in England and Wales are published by the Office for National Statistics (ONS) in their series on mortality statistics. These can be accessed from the ONS website at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths

The Ministry of Justice’s coroner statistics differ from ONS figures because they count two different, albeit related, events. The Ministry of Justice’s coroner statistics provide information on the number of deaths which are reported to coroners in England and Wales. These include deaths reported to coroners which occurred outside England and Wales. The ONS mortality statistics, based on death registrations, report the number of deaths registered in England and Wales in a particular year irrespective of whether a coroner has investigated the death. These do not include deaths that occurred outside England and Wales. Additionally, ONS counts deaths when they have been registered whilst coroners count deaths when they are reported.

The proportion of deaths which are reported to coroners has been estimated using death registration figures published by ONS. Estimates for 2023 have been calculated using ONS’ monthly provisional figures on death registrations, while percentages for 2022 and earlier years have been calculated using final annual death registration figures for the relevant year. A consequence of the statutory system is that there can be a sometimes considerable time lag between the date when the death occurred and when the death is registered. Deaths reported to a coroner would not be added to the deaths register until the coroner has concluded their investigation. Therefore it is advised that caution is used when using these figures.

This publication includes figures for deaths reported to coroners which occurred in state custody. Statistics on deaths in prison custody are also published by His Majesty’s Prison and Probation Service (HMPPS), and are the official source of information on prison deaths. The HMPPS figures can be found in the ‘Safety in Custody’ bulletin, which is available at: https://www.gov.uk/government/collections/safety-in-custody-statistics

Differences between the two sets of figures are in part due to three main reasons. Firstly, there is a time lag in reporting processes. The figures for deaths in custody in this publication relate to those deaths when they have been reported to a coroner in the given year and then reported to MoJ, whereas for the HMPPS publication, deaths are recorded directly after they have occurred. Secondly, HMPPS figures include all deaths which have occurred in prision custoday including deaths which occurred whilst an offender has been Released on Temporary Licence (ROTL) for medical reasons. Deaths while on ROTL are classed as a separate category in the Coroners report, and cannot be broken down between ROTL for medical reasons and other types of ROTL. Finally, if the coroner is unaware that the death occurred in State Detention or classes it under another type of establishment, it may not be recorded as a death in State Detention by the coroner.

This publication also includes figures on deaths reported to coroners of individuals detained under the Mental Health Act (MHA) – similar statistics are published by the Care Quality Commission (CQC)^{[footnote 2]}. Differences between the two sets of figures are likely to be due to a time lag in reporting processes: coroners are required to conduct an investigation within six months of the death being reported to them whilst the CQC receives reports of all deaths of individuals detained under the MHA in a particular year. In addition, the reporting time periods are different (the CQC report is financial year), and also not all deaths reported to the CQC are reported to a coroner.

This publication includes the number of deaths with a conclusion of suicide recorded at inquest - statistics on suicide deaths are also published by the ONS^{[footnote 3]}. The ‘ONS Suicide Statistics UK’ series uses the national statistics’ definition of suicide: deaths given an underlying cause of intentional self-harm or an injury/poisoning of undetermined intent. In 2016, this definition has been modified to include deaths from intentional self-harm in 10- to 14-year-old children in addition to deaths from intentional self-harm and events of undetermined intent in people aged 15 and over. For coroners, a short-form conclusion of suicide requires evidence of intent as well as the death being self-inflicted.

2.2 Users of the statistics

The main users of these statistics are coroners, Ministers and officials in central government to assist in developing coroners’ policy and its subsequent monitoring. Other users include the Chief Coroner, local authorities (who are responsible for appointing and paying coroners as well as funding their services), other central government departments, and those non-governmental bodies, including various voluntary organisations, with an interest in coroners and inquests. The statistics are used to monitor the volume and types of cases dealt with by coroners in England and Wales each year.

2.3 Map of coroner areas in England and Wales, 2023

2.4 Key to coroner areas

North East	East of England
101 – County Durham and Darlington	601 – Bedfordshire and Luton
104 – North Northumberland	602 – Cambridgeshire and Peterborough
105 – South Northumberland	604 – Essex
106 – Teesside and Hartlepool	605 – Hertfordshire
107 – Gateshead and South Tyneside	607 – Norfolk
108 – Newcastle and North Tyneside	611 – Suffolk
110 – Sunderland
	London
North West	701 – City of London [not visible]
201 – Cheshire	702 – East London
203 – Cumbria	703 – Inner North London
205 – Manchester City	704 – Inner South London
206 – Manchester North	705 – Inner West London
207 – Manchester South	706 – North London
208 – Manchester West	707 – South London
209 – Lancashire and Blackburn with Darwen	708 – West London
210 – Blackpool and Fylde
213 – Sefton, Knowsley and St Helens	South East
214 – Liverpool and the Wirral	801 – Berkshire
	802 – West Sussex, Brighton and Hove
Yorkshire and the Humber	803 – Buckinghamshire
301 – East Riding and Hull	804 – East Sussex
302 – North Lincolnshire and Grimsby	805 – Hampshire, Portsmouth and Southampton
303 – North Yorkshire and York	809 – Isle of Wight
306 – South Yorkshire (Eastern)	810 – Central and South East Kent
307 – South Yorkshire (Western)	811 – Mid Kent and Medway
308 – West Yorkshire (Eastern)	812 – North East Kent
309 – West Yorkshire (Western)	813 – North West Kent
	814 – Milton Keynes
East Midlands	815 – Oxfordshire
401 – Derby and Derbyshire	816 – Surrey
403 – Leicester City and South Leicestershire
404 – Rutland and North Leicestershire	South West
406 – Lincolnshire	901 – Avon
409 – Northamptonshire	902 – Cornwall and Isles of Scilly
410 – Nottinghamshire	903 – Exeter and Greater Devon
	904 – Plymouth, Torbay and South Devon
West Midlands	906 – Dorset
501 – Herefordshire	908 – Gloucestershire
502 – Shropshire, Telford and Wrekin	910 – Somerset
504 – Staffordshire and Stoke on Trent	912 – Wiltshire and Swindon
507 – Warwickshire
508 – Birmingham and Solihull	Wales
509 – Black Country	1001 – South Wales Central
510 – Coventry	1003 – Carmarthenshire and Pembrokeshire
512 – Worcestershire	1004 – North Wales (East and Central)
	1005 – Ceredigion
	1006 – Gwent
	1007 – Swansea and Neath Port Talbot
	1009 – North West Wales

3. Structure and Functions of Coroners

Under the Coroners and Justice Act 2009 (“the 2009 Act”), each coroner area has one senior coroner, and one or more assistant coroners. A coroner area may also have one or more area coroners (who may function as a deputy to the senior coroner).

For a list of the current coroner areas and information on changes to these areas, please see Annex A of the Coroners statistics bulletin.

3.1 Chief Coroner

The 2009 Act created the post of Chief Coroner to provide judicial oversight of the coroner system and leadership, guidance and support to coroners. The Chief Coroner’s primary responsibilities include:

• providing support, leadership, and guidance for around 500 coroners throughout England and Wales

• representing the interests of coroners to Ministers and Parliament

• working with the Judicial College to provide coroner training

• consenting to coroner appointments

• providing an annual report to the Lord Chancellor

On 22 December 2020 the Lord Chief Justice, after consultation with the Lord Chancellor, appointed His Honour Judge Thomas Teague KC as the third Chief Coroner of England and Wales.

Further information on the Chief Coroner is available at: https://www.judiciary.uk/related-offices-and-bodies/office-chief-coroner/

3.2 Chief Coroner’s annual report

The Chief Coroner’s annual report to the Lord Chancellor is a statement on the coroner system for the previous calendar year. The annual report is published on the Corporate information section of the GOV.UK website^{[footnote 4]}.

Coroners are required to notify the Chief Coroner of any investigation that lasts more than a year and to notify the Chief Coroner of the date on which any such investigation was subsequently concluded. This information is normally published by the Chief Coroner as an annex to his Annual Report.

3.3 The coroner jurisdiction

A coronial investigation is a form of summary justice designed to provide answers to four statutory questions, namely who the deceased was and when, where and how (usually confined to meaning ‘by what means’) the deceased came by his or her death.

Coroners are only required in law to investigate deaths reported to them which fulfil certain statutory criteria. Under section 1 of the Coroners and Justice Act 2009, a coroner has a duty to investigate a death if:

1. the coroner is made aware that the body is within that coroner’s area; and
2. the coroner has reason to suspect that: a. the deceased died a violent or unnatural death; b. the cause of the death is unknown; or c. the deceased died while in custody or state detention.

The coroner’s investigation can culminate in a court hearing called an inquest.

The majority of deaths reported to coroners do not proceed to an inquest, either because the coroner decides - as part of preliminary inquiries – that the duty to investigate a death does not arise, or because, having opened an investigation under section 1, it becomes clear that the death resulted from natural causes.

These proceses may (but do not have to) involve a post-mortem examination.

3.4 Inquest findings

If an inquest is held as part of a coroner investigation, section 10 of the 2009 Act requires the coroner (or the jury if there is one) to make a ‘determination’ of the matters to be ascertained by the investigation and make ‘findings’ for registration purposes.

In totality this process provides the answers to the four questions (‘who’, ‘where’, ‘when’ and ‘how’), provides an overarching explanation of the death in the form of a ‘conclusion’ (which is what used to be known in law as a ‘verdict’) and provides information to the Registrar for the purposes of registering the death.

Conclusions are recorded in nearly all cases that proceed to inquest. The exceptions are inquests adjourned by the coroner if, for example, criminal proceedings take place. The inquest is usually not resumed because the relevant evidence has been heard elsewhere. Most inquests are held by a coroner sitting alone but some types of case must be held with a jury (as prescribed by the 2009 Act). In addition, the coroner also has discretion to hold any inquest with a jury if they think there is sufficient reason to do so.

There are two alternatives for conclusions as sanctioned by the 2009 Act, the 2013 Rules and the common law: (1) a short-form conclusion; and (2) a narrative conclusion. It is also permissible to combine the two types of conclusion. The list of available short-form conclusions is:

• accident or misadventure
• alcohol/drug related
• industrial disease
• lawful killing
• unlawful killing
• natural causes
• open
• road traffic collision
• stillbirth
• suicide

Figure 1 shows the possible outcomes involved when a death is reported to a coroner.

3.5 Figure 1: Deaths reported to coroners, 2023

Conclusions recorded in 2023 may relate to deaths from 2023 or earlier years. It is not possible to follow the flow of individual cases through the system due to the way the data is collected.

3.6 Suspension of investigation / adjournment of inquest

Under Schedule 1 to the 2009 Act, a coroner must suspend an investigation (and if an inquest has been opened, adjourn that inquest) in the following circumstances:

• If asked to do so by a prosecuting authority because someone may be charged with a homicide or related offence involving the death of the deceased (paragraph 1);
• When criminal proceedings have been brought in connection with the death (paragraph 2) ;
• Where there is an inquiry under the Inquiries Act 2005 (paragraph 3);
• If it appears to the coroner that it would be appropriate to suspend an investigation or adjourn an inquest (paragraph 5).

3.7 Average time taken to complete an inquest

For the purpose of determining the average time taken to complete an inquest, the time period is deemed to start from the day the death was reported to the coroner until either (a) the day the inquest is concluded by the delivery of a conclusion or (b) the day the coroner certifies that an adjourned inquest will not resume.

The average time for an inquest to be conducted is estimated by asking coroners, in their annual return, to state how many inquests were concluded within five time bands, which are: within one month; 1-3 months; 3-6 months; 6-12 months; and over 12 months. All the inquests falling within a time band are then assumed to have been completed at or near the mid-point of the relevant time bands for the purposes of calculating the average. However, inquests within the “under one month” band are assumed to have taken 3 weeks for the purpose of this estimation, and those inquests taking over a year to conclude are deemed to have taken 18 months, although the time-band itself is open-ended. Numbers are then aggregated and the average figure (in weeks) calculated in the normal way.

Only deaths occurring within England and Wales are included in the calculation. Statistics are not collected on the time taken for inquests where the death occurred outside England and Wales. Deaths occurring abroad are often significantly delayed because, for example, of difficulty in obtaining reports from other countries.

3.8 Treasure

In England and Wales a coroner also handles investigations regarding finds reported to them under the provisions of the Treasure Act 1996. By law, all treasure finds must be reported to the coroner within 14 days except where they occurred before 24 September 1997, in which case the find is dealt with under common law “Treasure Trove”. Such cases are extremely rare and the vast majority of cases fall under the Treasure Act 1996. Not all finds need be the subject of an inquest. For more information please see: www.legislation.gov.uk/ukpga/1996/24/contents

In July 2023, the definition of treasure was expanded to include objects that contain metal, are at least 200 years old and meet a specified threshold of historical, archaeological or cultural significance. Prior to this, newly discovered artefacts could only be legally classified as treasure if they were more than 300 years old and made of precious metal or were part of a collection of valuable objects or artefacts.

4. Data Quality and Sources

The figures presented in the coroner statistics are collected via statistical returns completed by coroners. For the calendar year 2023, all coroner area returns were received electronically. The process by which coroners provide their returns can vary according to the case management system they use. The vast majority of coroner services use a case management system provided by an external provider. Although care is taken in completing, analysing and quality-assuring the data provided in the statistical returns, the figures are, of necessity, subject to possible inaccuracies inherent in any large-scale collection of this type. Every effort is made, however, to ensure that the figures presented in this publication are accurate and complete.

Returns are individually quality-assured and validated in a process that highlights inconsistencies between years, and between areas. Checks are made to ensure that each return is arithmetically correct, e.g. subtotals and overall totals are correctly summed. Unusual or outlying values found within returns are queried with the data supplier to confirm whether these are correct, or that an error exists in the information provided which requires amendment.

Coroners are independent judicial office-holders, supported by the relevant local authority, and there is variation in the way each coroner’s area is structured and managed, and in the mechanisms they have in place for discharging their duties under the 2009 Act. For example, there are differences between coroners as to which cases they consider constitute a substantive “reported death” (and are therefore reported in their statistics) where little or no action is required on their part and no post-mortem or inquest is held. As such, the statistics reflect those cases which each individual coroner considers to be a death reported to them, and the figures for different coroner areas should be compared on this basis.

5. Coroner Area Amalgamations

The following table summarises the coroner area amalgamations that have occurred since 2012. A list of all amalgamations since 2000 is included in the Coroners statistical tool published alongside this bulletin.

Date Change Effective	Old areas	New area(s)	Nature of amalgamation
01-Jan-12	Black Country; Wolverhampton	Black Country	2 into 1
01-Apr-12	West Lincolnshire; Spilsby and Louth	Central Lincolnshire	2 into 1
01-Jun-12	Boston and Spalding; Stamford	South Lincolnshire	2 into 1
01-Jan-13	Central North Wales; North East Wales	North Wales (East and Central)	2 into 1
26-Jul-13	Carmarthenshire; Pembrokeshire	Carmarthenshire and Pembrokeshire	2 into 1
26-Jul-13	Darlington and South Durham; North Durham	County Durham and Darlington	2 into 1
26-Jul-13	Derby and South Derbyshire; North Derbyshire	Derby and Derbyshire	2 into 1
26-Jul-13	Bournemouth, Poole and Eastern Dorset; Western Dorset	Dorset	2 into 1
26-Jul-13	Essex and Thurrock; Southend-on-Sea	Essex	2 into 1
26-Jul-13	Plymouth and South West Devon; Torbay and South Devon	Plymouth, Torbay and South Devon	2 into 1
26-Jul-13	Bridgend and Glamorgan Valleys; Powys	Powys, Bridgend and Glamorgan Valleys	2 into 1
26-Jul-13	Mid and North Shropshire; South Shropshire; Telford & Wrekin	Shropshire, Telford and Wrekin	3 into 1
26-Jul-13	Neath and Port Talbot; City and County of Swansea	Swansea and Neath Port Talbot	2 into 1
01-Aug-14	Queens Household	N/A	Abolished
01-Jan-15	North and West Cumbria, South and East Cumbria	Cumbria	2 into 1
02-Apr-15	Liverpool; The Wirral	Liverpool and Wirral	2 into 1
01-Aug-15	North and East Cambridgeshire; South and West Cambridgeshire; Peterborough	Cambridgeshire and Peterborough	5 into 1
01-Apr-16	East Somerset; West Somerset	Somerset	2 into 1
01-Apr-16	Cornwall; Isles of Scilly	Cornwall and Isles of Scilly	2 into 1
01-Apr-16	Powys, Bridgend and Glamorgan Valleys; Cardiff and Vale of Glamorgan	South Wales Central	2 into 1
01-Apr-17	Central Lincolnshire; South Lincolnshire	Lincolnshire	2 into 1
01-Dec-17	Blackburn, Hyndburn and Ribble Valley; Preston and West Lancashire; East Lancashire	Lancashire and Blackburn with Darwen	3 into 1
01-Aug-18	Teesside; Hartlepool	Teesside and Hartlepool	2 into 1
01-Apr-20	Central Hampshire; North East Hampshire; Portsmouth and South East Hampshire; Southampton and New Forest	Hampshire, Portsmouth and Southampton	4 into 1
01-Apr-22	York City; North Yorkshire (Eastern); North Yorkshire (Western)	North Yorkshire and York	3 into 1
01-Apr-23	Newcastle upon Tyne; North Tyneside	Newcastle and North Tyneside	2 into 1
01-Apr-23	Brighton and Hove; West Sussex	West Sussex, Brighton and Hove	2 into 1
01-Oct-23	Staffordshire South; Stoke-on-Trent and North Staffordshire	Staffordshire and Stoke on Trent	2 into 1

6. Useful Publications

Prior to the transfer of responsibility for coroner law and policy to the Ministry of Justice, the Home Office published statistical bulletins based on coroners’ annual returns, from 1980. The last four bulletins published in the Home Office Statistical Bulletin series were as follows: for year 2003, bulletin 9/04; for 2002, bulletin 6/03; for 2001, bulletin 3/02; and for year 2000, bulletin 7/01. These may be found at:

webarchive.nationalarchives.gov.uk/20110218135832/http://rds.homeoffice.gov.uk/rds/hosbarchive.html

Statistics on registered deaths in England and Wales are published by the Office for National Statistics (ONS). These can be accessed from the ONS website at:

www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths

ONS also published a statistical bulletin on the number of suicides in the UK, based on the registered deaths data, and can be found at the following website:

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesintheunitedkingdom/2021registrations

Statistics on deaths in prison custody are also published by His Majesty’s Prison and Probation Service (previously the National Offender Management Service, NOMS), accessible via the following link:

www.gov.uk/government/collections/safety-in-custody-statistics

An annual report on the operation of the Treasure Act 1996 is published by the Department for Culture, Media and Sport. For more information please see:

https://www.gov.uk/government/collections/treasure-and-portable-antiquities-statistics

The Chief Coroner has issued a practical guide for coroners, accompanied by a set of standard letters and forms, for use in treasure cases in England and Wales, accessible via the Chief Coroner’s website:

www.judiciary.gov.uk/related-offices-and-bodies/office-chief-coroner/

The Care Quality Commission (CQC) publishes an annual report on mental health, which includes figures they have collected in relation to deaths while detained under the Mental Health Act:

www.cqc.org.uk/content/monitoring-mental-health-act-report

7. Glossary

The following definitions are intended as a guide to the meaning of terms in the Coroners Statistics bulletin concerning coroners and their work; more detailed definitions will be found in the 2009 Act and the Treasure Act 1996 (see links below).

• www.legislation.gov.uk/ukpga/2009/25/contents
• www.legislation.gov.uk/2013?title=coroners
• www.legislation.gov.uk/ukpga/1996/24/contents

Chief Coroner

The judicial head of coroner services in England and Wales, responsible for setting national standards of service, training coroners and their officers and other staff and issuing guidance to them.

Coroner

A coroner is an independent judicial office holder, appointed by a local authority within the coroner area. Some coroners are appointed to more than one coroner area. Coroners are invariably lawyers but coroners appointed before implementation of the 2009 Act may be doctors. They are responsible for the investigation of violent or unnatural deaths, deaths of unknown cause, and deaths in custody or state detention which are reported to them (see ‘Deaths reported to coroners’ section below).

Conclusion

Put generally, this is the decision the coroner (or jury) reaches at the end of an inquest providing the overarching explanation of the circumstances of death. It will be consistent with other matters addressed by the coroner or jury, for example the answers to the four statutory questions. Please see Chief Coroner’s Guidance No.17 Conclusions: Short-Form and Narrative - Courts and Tribunals Judiciary.

Discontinuance

Coroners are able to discontinue an investigation where the death did not occur in custody or other state detention and a natural cause becomes clear prior to an inquest, either following a post-mortem examination or (following amendment of section 7 of the 2009 Act in June 2022) from other evidence.

Inquest

This is a public hearing held by a coroner in order to establish who has died, and how, when and where they came by their death. It forms part of the coroner’s investigation and is required if the coroner has not discontinued the investigation in the circumstances set out above. An inquest does not establish any matter of criminal or civil liability and does not seek to blame anyone or apportion blame between people or organisations. The inquest may be held with a jury, depending on the circumstances of the death or at the coroner’s discretion.

Investigation

The coroner’s investigation is the process by which the coroner establishes who has died, and how, when, and where they died. The coroner may be required to hold an inquest as part of the investigation (see above). The coroner has a duty under the 2009 Act to investigate a death if:

1. the coroner is made aware that the body is within that coroner’s area, and

2. the coroner has reason to suspect that:

   a. the deceased died a violent or unnatural death;

   b. the cause of the death is unknown; or

   c. the deceased died while in custody or state detention.

Juries

Nearly all inquests are held by a coroner sitting alone, without a jury. A jury must be summoned if the senior coroner has reason to suspect:

a. that the deceased died while in custody or otherwise in state detention, and that either the death was violent or unnatural, or the cause of death is unknown;

b. that the death resulted from an act or omission of a police officer, or a member of a service police force in the purported execution of his or her duty;

c. that the death was caused by a notifiable accident, poisoning or disease (i.e. under certain statutory reporting obligations under the Health and Safety Act 1974 or any other Act, and in certain other circumstances, especially where there may be a continuing or recurring danger to the public).

Juries in coroner inquests comprise of between seven and eleven members.

Narrative conclusion

This is where the coroner makes a brief and factual statement at the conclusion of the inquest rather than returning a short-form conclusion.

Non-inquest cases

This is where the coroner’s investigation is concluded without an inquest being held.

Out of England Order

To take a body of a deceased person out of England and Wales (whether or not the death has been reported to the coroner), notice must be given to the coroner within whose area the body is lying. This notice allows the coroner to consider whether an investigation is necessary. When the coroner gives permission for the removal of the body, an Out of England order is issued.

Post-mortem examination

This is a detailed examination of a body after death to establish the medical cause of death. A coroner’s post-mortem examination is carried out by a suitable medical practitioner such as a pathologist (a doctor who specialises in medical diagnosis by examining body organs, tissues and fluids) of the coroner’s choice. A coroner may commission a post-mortem examination whether or not an inquest is held, particularly if the cause of death is not clear. In many cases a post-mortem examination is conducted in order to determine whether or not an investigation or an inquest is necessary.

Registered deaths

All deaths in England and Wales must be registered with the Registrar of Births and Deaths. The term ‘registered deaths’ in the Coroners Statistics bulletin refers to deaths registered within a specific time period (in this case, calendar years). Statistics on registered deaths in England and Wales are published by the Office for National Statistics (ONS) in their series on mortality statistics. At the time of the Coroners Statistics 2023 publication, final figures had not been published for the number of registered deaths in 2023, but a provisional figure has been derived from the monthly registration figures which are published by ONS at regular intervals.

Suspensions under Schedule 1 to the 2009 Act

Under Schedule 1 to the 2009 Act a coroner must suspend an investigation (and if an inquest has been opened, adjourn that inquest) in the following circumstances:

• If asked to do so by a prosecuting authority because someone may be charged with a homicide or related offence involving the death of the deceased (paragraph 1);
• When criminal proceedings have been brought in connection with the death (paragraph 2);
• Where there is an inquiry under the Inquiries Act 2005 (paragraph 3,);
• If it appears to the coroner that it would be appropriate to do so (paragraph 5).

Timeliness of inquests

For the purpose of determining the timeliness of inquests, the time taken to conduct an inquest is deemed to be from the day the death was reported to the coroner until either (a) the day the inquest is concluded by recording a conclusion or (b) the day the coroner certifies that an adjourned inquest will not be resumed.

The average time for an inquest to be conducted is estimated by asking coroners to state in their annual return to state how many inquests were concluded within five time bands: within one month; 1-3 months; 3-6 months; 6-12 months; and over 12 months. All the inquests falling within a time-band are then assumed to have been completed at or near the mid-point of the relevant time-bands for the purposes of calculating the average, although inquests within the “under one month” band are assumed to have taken 3 weeks for this purpose of this estimation, and inquests taking over a year to conclude are deemed to have taken 18 months, although the time-band itself is open-ended. Numbers are then aggregated and the average figure (in weeks) calculated in the normal way.

Note: only deaths occurring within England and Wales are included in the calculation. Statistics are not collected on the time taken for inquests where the death occurred outside England and Wales. Deaths occurring abroad are often significantly delayed because, for example, of difficulty in obtaining reports from other countries.

Treasure and treasure trove

Treasure is defined as:

1. Any object at least 300 years old which:

   a. Is not a coin but has metallic content of which at least 10% by weight is precious metal (i.e. gold or silver); and

   b. Is one of at least 2 coins in the same find which are at least 300 years old and have that percentage of precious metal; or

   c. Is one of at least 10 coins in the same find which are at least 300 years old

2. Any object at least 200 years old which the Secretary of State considers to be of outstanding historical, archaeological or cultural importance.

3. Objects of historical importance more than 200 years old and containing metal.

For more information please see the below link:

https://www.gov.uk/government/news/thousands-more-treasures-to-be-saved-for-the-nation-as-rules-about-discoveries-are-changed

Treasure Trove relates to treasure finds made before commencement of the Treasure Act 1996 on 24 September 1997.

Coroners have jurisdiction to inquire into any treasure which is found in their area and to establish who the finder is.

1. The Coroners Act 1988 was repealed in July 2013 with the exceptions of section 13 (application for a fresh coroner investigation or inquest) and 4A (8) (a coroner in Wales being regarded as a coroner for the whole of Wales). ↩

2. The Care Quality Commission (CQC) annual report on Monitoring the Mental Health Act can be found here: http://www.cqc.org.uk/content/monitoring-mental-health-act-report. ↩

3. For more on ONS Suicide please visit: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesintheunitedkingdom/previousReleases ↩

4. https://www.gov.uk/government/publications/chief-coroners-annual-report-2023 ↩