Coroner statistics 2025: Key trends and what they mean for families in England and Wales

However, we must remember that these statistics represent real people. Behind the data are bereaved families seeking clarity and peace of mind. Whilst the report provides an overview of the legal landscape, it also highlights the delays and challenges families encounter during a coroner’s investigation.

One of the most striking findings is the sharp fall in deaths reported to coroners.

In 2025, 147,814 deaths were referred to coroners, a 15% decrease since 2024 and the lowest figure since the annual series began in 1995. But crucially, this does not mean fewer people are dying. Instead, the change appears closely linked to the introduction of the statutory Medical Examiner system in September 2024.

A Medical Examiner provides an independent review of a death before a death certificate is issued. Their role is to scrutinise the cause of death, identify concerns and ensure appropriate referrals are made where necessary. As a result, many deaths that may previously have been referred to a coroner are now resolved without the need for a coronial investigation.

The change is intended to create greater consistency and confidence in the death certification process. We explored these developments in our review of the Chief Coroner’s annual report.

Despite a decline in the total number of reported deaths, a higher proportion of these cases are proceeding to full inquests. In 2025, 24% of reported deaths resulted in an inquest being opened, representing the highest proportion since 1995.

This trend indicates that cases now reaching coroners increasingly involve uncertain, unexplained, or complex circumstances. As Medical Examiners increasingly certify deaths that do not require legal investigation, coroners are concentrating more on cases necessitating detailed scrutiny.

The influence of the Medical Examiner system is also potentially evident in inquest outcomes, as natural causes conclusions declined by 24% in 2025 to approximately 3,700 cases.

Historically, some deaths were referred to the coroner despite the absence of any dispute regarding the medical cause of death, often due to the unavailability of a doctor to complete certification. The implementation of Medical Examiners has reduced the necessity for many such referrals.

For families, avoiding unnecessary involvement in the coronial process in straightforward cases may reduce additional stress and delays at an already challenging time.

The report identifies a significant increase in deaths occurring in custody or other state detention, with 622 such deaths reported to coroners in 2025. This represents a 13% year-on-year increase and is the highest figure since 2017.

This increase was driven by an 8% rise in deaths in prison custody and a 21% rise in deaths involving individuals detained under the Mental Health Act.

When a death occurs in custody or state detention, legal requirements mandate that a coroner investigate the death. These investigations are essential for identifying potential failures in care and determining whether changes could prevent similar deaths in the future.

For families, such inquests can be particularly challenging, as they frequently involve detailed examination of public authorities, healthcare providers, or custodial institutions.

A notable trend is the increase in suicide conclusions, reaching the highest level since 1995. This increase was driven entirely by male suicides, whereas female suicide conclusions decreased during the same period.

These figures require cautious interpretation. Coroners record conclusions at the completion of an inquest rather than at the time of death. As inquests may take several months to conclude, some suicide conclusions recorded in 2025 pertain to deaths that occurred in previous years.

Nevertheless, the data highlights the ongoing need to understand and address factors contributing to suicide, particularly among men.

Families often tell us that one of the most difficult aspects of the coronial process is the wait for answers, and these latest figures show that the average time taken to complete an inquest remained broadly unchanged at 31.3 weeks.

Whilst it’s encouraging that waiting times have not increased further, this still means many families spend more than seven months waiting for answers, making the grieving process significantly harder.

In 2025, coroners issued 654 Prevention of Future Death (PFD) reports, an 8% decrease compared with 2024. A PFD report is produced when a coroner believes action should be taken to reduce the risk of similar deaths occurring in the future. Such reports can lead to important changes in healthcare, public services, workplaces and other settings.

Although the number has fallen slightly, PFD reports remain one of the most significant ways in which coronial investigations contribute to public safety and wider learning, and families can take great comfort in knowing their concerns are being escalated.

Collectively, the 2025 statistics indicate that the coronial system is becoming increasingly selective, with a reduction in the number of deaths referred but a higher proportion advancing to formal investigation and inquest. The implementation of the Medical Examiner system is reshaping the entry pathway into the process, enabling coroners to allocate greater resources to cases that present substantive questions regarding the circumstances of death.

However, the data also reveals persistent challenges. Deaths occurring in custody and state detention have risen, suicide conclusions remain at historically high levels, and the average waiting time for an inquest conclusion exceeds seven months. Although the system is undergoing change, the necessity for timely investigations, rigorous scrutiny, and transparent communication remains constant.

For bereaved families, these statistics represent more than performance metrics or workload indicators. They embody lived experiences of loss, uncertainty, and the pursuit of answers. As the coronial landscape evolves, it is essential to ensure that families receive adequate support, information, and opportunities for effective participation in the process, which is fundamental to sustaining public confidence in the system.