The Chief Coroner’s annual report for 2024 was published on 11 September 2025, marking the first report from Her Honour Judge Alexia Durran since her appointment in May 2024.
The report provides a national overview of the Coroner service in England and Wales and highlights key developments that healthcare professionals should be aware of. It offers insights into trends in Prevention of Future Deaths (PFD) reports, inquest delays, and the implementation of the statutory medical examiners system.
Key takeaways
Decrease in number, increase in complexity
In 2024, there was a 10% reduction in the number of deaths reported to a Coroner compared to 2023. There were 174,900 deaths reported, marking the lowest level reported since 1995. Despite this, the Chief Coroner notes that the complexity of cases being reported is growing and that the number of deaths requiring a post-mortem increased.
Delays
The report contains a statutory summary of cases lasting over 12 months. The Chief Coroner acknowledges that delays are often caused by external factors such as police investigations, regulatory processes, or resource constraints. The Chief Coroner plans to refine future reporting by asking Coroner areas to estimate how many of their cases are likely to last for more than one year, to inform her engagement with certain areas.
Increase in PFD reports
713 PFD reports were issued in 2024; an increase from 569 in 2023. These reports are vital for identifying systemic risks to prevent future deaths and driving improvements in patient safety, but the Chief Coroner notes that once a PFD report is issued, a Coroner has no legal power to take further steps (other than extending the response deadline). The annual report highlights that the lack of any enforcement mechanism means that PFD responses are not always provided.
Statutory medical examiner scheme
The new statutory medical examiner scheme came into force on 9 September 2024, modernising a process that had largely remained unchanged for over half a century. Under this scheme, all non-coronial natural deaths must be reviewed by a medical examiner. The Chief Coroner is hopeful that the slight drop in referrals to the Coroner service reflects this change, with clearer trends expected in next year’s data. Healthcare providers should ensure staff are aware of the scheme.
Focus on consistency and training
The Chief Coroner emphasises the importance of consistency across Coroner areas and continued training and wellbeing support for Coroners. For healthcare providers, this may lead to more predictable inquest processes.
Final thoughts
The annual report reflects a proactive approach from the Chief Coroner, with a clear focus on improving timeliness, transparency, and collaboration. It will be helpful for healthcare professionals to consider these developments, particularly when preparing for inquests or reviewing internal procedures.
You can read the full report here.
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