Key takeaways
Coroner services face rising case complexity
Delays and resource pressures highlighted in latest report.
Focus on training and consistency across jurisdictions
Improved guidance aims to standardise practices nationwide.
Digital transformation remains a key priority
Technology adoption expected to streamline inquest processes.
Every year, the Chief Coroner is required to publish an annual report. The aim is to ensure accountability, oversight and guide improvements.
The 2024 report is the first report written under Judge Alexia Durran, who became Chief Coroner on 25 May 2024. Judge Durran focuses on two key areas for improvement:
Long delays
The report highlights that many cases are taking more than a year to fully investigate, with some local areas having over 400 of such cases. This remains a key focus for improvement of the coronial system, given the significant impact which delays have on bereaved families and witnesses. Delays also impair the recollection of witnesses.
Whilst the Chief Coroner appreciates a significant proportion of cases are dependent on external investigations outside of the coroners’ control (such as ongoing criminal investigations, meaning the coroners’ investigations are rightly paused), the under-funding in local councils provides additional challenge for dealing with cases quickly. The Chief Coroner has pledged to work closely with jurisdictions to anticipate where delays are likely and to understand what support can be provided.
Support for coroners
In 2024, coroners were included in the annual Judicial Attitude Survey for the first time. The results showed that coroners reported feeling the highest stress levels of any area of judicial office. The Chief Coroner has committed herself to improving these results, particularly in relation to enhancing resources and workloads.
Key statistics
174,900 deaths were reported to the coroner, down 10% from 2023 and the lowest since 1995.
Deaths in state detention were up 11% in the last year, driven largely by increases in deaths in prison custody.
Average inquest completion time reduced slightly, from 31.5 weeks in 2023 to 31.2 weeks in 2024.
713 Prevention of Future Deaths (PFD) reports were issued in 2024, an increase of 25% compared to 2023.
Lessons identified for Health and Social Care Providers
Engage early in the coronial processes
Prompt and transparent engagement with coroners can help prevent delays. Collaborating with local coroners and establishing clear lines of communication is vital. Delays in investigation reports (such as Patient Safety Incident Investigations) are often cited as reasons for inquest delay - organisations should carefully consider their internal processes to avoid contributing to delays. Health and Social Care providers should also ensure staff are provided with training on the importance of providing detailed factual statements in a timely manner.
Review and respond promptly to all PFD reports
PFDs are seen by the Chief Coroner as signalling systemic risks in an organisation. At the date of publication of the Chief Coroner’s Annual Report, there remained 16 PFD’s issued in 2024 with a response outstanding. Receipt of a PFD and failure to act in response to the concerns identified can lead to reputational harm, CQC concern, or media scrutiny. Submitting evidence of learning to an Inquest will help improve patient safety and mean the Coroner’s duty to issue a PFD is not engaged.
Support for bereaved families
The Chief Coroner’s Annual report maintains the position that the bereaved should always be at the heart of the coronial process. Health and Social Care providers can encourage this by ensuring clear and transparent communication channels for bereaved relatives, so that they know who to contact, what processes apply and explanation of any delays.
