The Ministry of Justice has published the most recent Coroners Statistics Annual Bulletin of deaths reported to coroners in England and Wales in 2022.
The bulletin remains a useful barometer on the workload of coroners around the country and can be used to identify patterns and trends in inquest conclusions and times taken for cases to be heard.
Key data from the bulletin
- 7% increase in the number of deaths reported to coroners in 2022
- 36% of all registered deaths were reported to coroners in 2022 – this is the highest level since 2019
- Deaths in state detention, down 8% in the last year – the decrease was driven by a 20% fall in deaths in prison custody
- 11% more inquests opened in 2022
- Inquest conclusions up 10%
- Average time taken to complete an inquest fell by less than one week
- Prevention of Future Deaths reports down by 8%
Deaths in state detention
The numbers have decreased by 8% driven by a fall in the number of deaths in prison custody. There were 193 deaths of individuals subject to the Mental Health Act in detention in 2022. A 14% increase compared to 2021. By way of comparison, the CQC reported 270 deaths under the MHA in the 2021/22 financial year (so a slightly different time frame), down by 26% on the number they reported in the previous financial year.
300 deaths in prison were reported to coroners - a decreased of 20% (73 cases) compared to 2021.
Inquests opened
The number of inquests opened in 2022 increased by 3,511 (up 11%) to 36,273. This is the highest number of inquests opened since 1995, excluding the years when DoLS investigations were required.
There were 476 inquests held with juries in 2022 (representing 1% of all inquests), an increase of 11% compared to 2021.
Inquest conclusions
The data reveals a 10% increase in inquest conclusions recorded, with the largest seen in natural causes, accident/misadventure and unclassified conclusions. There were 35,643 inquest conclusions recorded in 2022, up 3,321 (10%) from 2021, which the statisticians explain reflect the change in the number of inquests opened and possibly due to a backlog caused by the Covid-19 pandemic. This is the highest level since 2016.
In 2022, the most common short form conclusions were:
- death by misadventure
- death by natural causes
- suicide
The number of suicide conclusions increased by 2% compared to 2021, to the highest level since 1995. As has always been the case, men are far more likely to die by suicide, with an increase of 3% compared to 2021, with the number in females falling (decreasing by 1% compared to 2021). How much of this is the filtering down of the Maughan decision and the change in the standard of proof remains to be seen.
Time taken to process an inquest
In 2022 it took an estimated average time of 30 weeks to process an inquest from the date of death until the conclusion of the inquest. The statisticians’ comment that this is still higher than the pre-pandemic levels in 2019 where it took an average 27 weeks to complete an inquest. It is likely to be due to the backlog of cases built up because of the pandemic. But we observe a postcode lottery: average time taken for cases to be heard varies by coroner area.
North Lincolnshire and Grimsby had the longest time to process an inquest at 72 weeks with Black Country processing time of an impressive 9 weeks. This disparity between regions is mainly due to differences that exist from one coroner area to another in terms of resources, the presence of hospital and prisons and the socio-economic make up of regions.
Prevention of Future Death reports
There were 403 PFD reports issued by coroners in 2022, down 8% compared to 2021.
Categories the reports covered included:
- Community healthcare
- Care Home Health related deaths
- Hospital Death (Clinical Procedures and medical management)
- Mental Health related deaths
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