Update on the coronial landscape: Chief Coroner’s combined annual reports

Judge Mark Lucraft QC’s combined sixth and seventh annual reports to the Lord Chancellor details the current state of the coroner service in 2018 to 2019 and 2019 to 2020. At a time when data on deaths dominates the news, the annual report may have passed inquest practitioners by. However, it provides a helpful summary on the current coronial landscape.

We take a look at the statistics.

Key figures from:


  • The number of registered deaths in England and Wales rose by 2% to 541,600 which was the highest recorded since 1999.
  • Deaths in state detention (excluding DoLs) fell from 528 in 2017 to 514 in 2018, a reduction in 3%. The decline is due to the 13% fall in deaths of individuals detained under the Mental Health Act 1983.
  • 423 jury inquests were held which equates to 1%-2% of all inquests.
  • Deaths in state detention remain of particular concern and generate many Prevention of Future Death (PFD) reports.


  • Number of registered deaths in England and Wales rose by 2% on the 2018 figures to 530, 857
  • 30,000 inquests were opened in 2019, an increase of 3%
  • Deaths in state detention (excluding DoLS) fell from 514 in 2018 to 478 in 2019, a reduction of 7%. The decline is driven by a 16% and 5% fall in reported deaths of individuals detained under the Mental Health Act 1983 and in prison custody respectively.
  • 527 inquests held with juries.

Cases over 12 months

  • 2,278 cases in England and Wales were not completed within 12 months of being reported to the coroner as at 2019. This is in the context of 220,600 deaths reported to the coroner in 2018 and 29,100 inquests being opened.
  • The figures for 2020 are not yet complete with coroners dealing with COVID-19 issues.
  • Often cases are put on ‘hold’ if there are ongoing police enquiries, Health and Safety Executive or Prison and Probation Ombudsman inquiries and criminal investigations, for example.
  • The impact of Covid-19 is likely to mean that there will be a significant increase in the numbers of over 12-month cases, including a ‘significant’ increase in the numbers of death referrals to coroners since March 2020 and the reduction in the ability of coroner to hold inquest hearings.

Covid-19: coroner response to the pandemic

  • Some Covid-19 deaths have been reported to coroners.
  • Anecdotally the pandemic has led to a ‘significant’ rise in the number of deaths referred to coroners but it has also led to a rise in the number of deaths referred to the coroner where Covid-19 does not appear to be involved. The full picture will not be known for some time until office ONS data on coroner cases become available in 2021.
  • Many jury inquests have had to be postponed.

Recent developments

The Chief Coroner has covered a number of topics that will be of interest to inquest practitioners from the merger of coroner areas to the rise in the number of area coroners who have been appointed and the appointment of two Deputy Chief Coroners. The report also includes updates on a number of topics from recent Chief Coroner guidance to the medical examiner scheme.

Judge Lucraft expresses concern at the dwindling resources of pathologists available to undertake post mortem examinations which is causing delays in inquest hearings.

The report also identifies that 505 PFDs were issued 2018/19, followed by 386 in 2019/20, a reduction which is attributed to the lockdown from March 2020 which effectively ended all inquest hearings from March to July. The Chief Coroner continues to encourage Coroners to write PFDs  “where appropriate”.

Concluding the report, Lucraft identifies a number of recommended law changes - a number of which were previously proposed in previous Chief Coroner annual reports.  Key areas of focus include:

  • Mergers of coroner areas
  • Discontinuance without a post-mortem examination
  • Inquests without a hearing
  • Fresh inquests
  • Representation of families

Do get in touch if you require support with an inquest – we have an expert and friendly team. 

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Every piece of content we create is correct on the date it’s published but please don’t rely on it as legal advice. If you’d like to speak to us about your own legal requirements, please contact one of our expert lawyers.

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