Key takeaways
Deaths in custody are rising sharply
Prison and mental health detentions saw notable increases.
Narrative conclusions are being used more often
Coroners are moving beyond short form outcomes in complex cases.
Prevention reports are up by 25 percent
Coroners are focusing more on avoiding future deaths.
When an inquest takes place, a Coroner (or Jury) will reach a determination as to the cause of death and provide a conclusion.
Chief Coroner’s guidance, alongside the recently published Coroner’s Bench Book, confirm that where possible short form conclusions should be used. The possible short form conclusions are outlined in the footnotes on the Record of an Inquest (contained within the Coroners (Inquests) Rules 2013) and include:
accident or misadventure
alcohol/drug related
industrial disease
lawful/unlawful killing
natural causes
open
road traffic collision
stillbirth
suicide
Where a Coroner or Jury considers it would not be appropriate to record one of the above conclusions, then either a combination of short form conclusions or a narrative conclusion may be returned.
Since 1995, short form conclusions have been utilised in the preparation of annual statistics and compared against previous years to provide information on deaths reported to the Coroner.
The Statistics
On 8 May 2025, the Ministry of Justice published the ‘Coroners Statistics 2024: England and Wales’. The annual publication is accessible here.
Of note from the Coroners Statistics 2024 is:
The most common inquest conclusion was death by misadventure (25% of all conclusions) followed by suicide (13%) and natural causes (12%).
There has been an 11% increase in deaths in state detention: with a 16% rise in deaths in prison custody and a 3% increase in deaths of individuals subject to Mental Health Act detention.
28% of all inquest conclusions were “unclassified”, which applies where the Coroner or Jury do not rely on just one short form conclusion or in cases where a narrative conclusion is provided. This is an increase of 9% compared to 2023 and reflects an increasing use of narrative conclusions.
Suicide conclusions decreased by 1% in 2024, however they remain at the second highest level since 1995.
56% of inquests related to those who were over 65 years old.
There was a 71% increase of inquests in writing where a Coroner can conduct an inquest based on documentary evidence alone (often referred to as Rule 23 inquests).
There was a 10% decrease in deaths being reported to the Coroner, with a total of 174,900 deaths reported. This is likely to be partly as a result of the added scrutiny as to the types of deaths reported to the Coroner following the introduction of Medical Examiners.
There was a 25% increase in Prevention of Future Death Reports in comparison to 2023, with a total of 713 being issued in 2024. This is 144 more than were issued in 2023, and 310 more than in 2022, representing a substantial increase over the last few years.
The Coroners Statistics provide a helpful holistic view of where the trends are in the Coroners’ Courts, providing an insight into the areas of focus for Coroners over the last 12 months and an indication as to where things are heading in the future. Of particular note is the rise in deaths in prison custody which indicates a significant challenge, not just for Coroners but for public policy makers as well, highlighting the need for significant investment and focus in this area.
Additionally, the increase in Prevention of Future Deaths reports is significant and demonstrates the continued focus by Coroners to exercise their duty to ensure robust lesson learning is implemented following a death to minimise, as far as possible, the risk of future deaths occurring.