Report of the chief coroner to the lord chancellor

Third annual report 2015-16 – an overview

The chief coroner’s annual report for 2016 has recently been published. The final report from the first chief coroner assesses the state of the coroner service between 2012 and 2016, and makes recommendations for the future. Rebecca Sharrock takes us through the highlights of the report.

The report makes a number of key points which will impact upon healthcare organisations and their involvement with inquests:

1. Standard procedure – An evaluation of the introduction of a standard procedure for reporting to the chief coroner in 2014 has led to a significant 52% decrease in the number of cases outstanding. There are now also fewer coroner areas with a high number of cases which are over 12 months old.
2. Positive statistics – Statistics for the last year show key positive trends. The average time of all cases from death to inquest has fallen from 28 weeks to 20 weeks, a reduction of 28.6%, and the percentage of deaths in which coroners have required a post-mortem has fallen from 38% of cases to 36%.
3. Good inquest practice – Over the last year the coroners’ compulsory training courses have concentrated on developing good practice in inquests, with particular focus on conclusions, narrative and using questionnaires. These courses have reported high levels of achievement in learning outcomes and usefulness, allowing for learning and discussion on good practice.
4. Continued training – This year’s annual continuation courses for coroners will focus on mental health issues in investigations and inquests. The chief coroner has continued to produce written guidance for coroners with a view to increased consistency and enhanced national standards.
5. The medical examiner system – A system whereby medical examiners give advice to doctors on medical cause of death is under consideration following a government consultation. Proposals include the introduction of statutory criteria for reporting deaths to coroners. It is envisaged that this will reduce the number of inappropriate referrals to coroners.
6. Preventing future death reports – Coroners continue to write reports to prevent future deaths and have produced 571 reports in 2015.
7. Second post-mortem examinations - Work has continued towards a new scheme to regulate the number of second post-mortem operations. This scheme is with a view to restricting additional examinations only to cases where there is a good and reasonable justification for them, limiting additional distress to families.
8. DoLS cases – The coroner has recommended that section 1 of the Coroners and Justice Act 2009 be amended to reduce the number of cases which must be held before a jury even where death is clearly from natural causes. It is proposed that deaths should be scrutinised by medical examiners and not subject to coroner investigation without a specific reason for referral to the coroner.

More information, particularly on proposals for medical examiners, can be found in the full report.  

The chief coroner concludes that significant progress has been made across England and Wales between 2012 and 2016, and that reform during this period has been positive and in the public interest. He believes that new national standards are now in place with a greater consistency of approach.