Chief Coroner’s Annual Report: Key Changes, Challenges, and Consistency Measures

Whilst preparing the report, the Chief Coroner found that in 2024 there was a decrease in deaths reported to the coroner. This shows a 10% reduction from the previous reporting year, and the lowest level reported since 1995. 

Although this is positive, it unfortunately did not have any positive impact on the delays faced in the coroner’s court. This is because it was found that the complexity of the cases reported is increasing – largely because the number of deaths that required a postmortem increased. 

It was found that delays often occur because coroners must wait for external investigations to finish before starting their own, making coroner’s courts increasingly reliant on other departments and agencies. 

The Chief Coroner explained that she is committed to scrutinising the number of cases that are taking longer than 12 months to conclude and promises to work closely with other bodies to better understand and anticipate where delays are likely to arise and what support can be given to mitigate these. 

Statistics were provided in relation to Prevention of Future Deaths (PFD) Reports. In 2024, 713 PFDs were issued, compared to 569 in 2023. This is positive, as it shows that coroners are increasingly making use of the opportunity to highlight risks and encourage organisations to take action to prevent similar tragedies. . However, the Chief Coroner took the opportunity to remind readers that coroners do not hold legal power or authority to recommend specific measures but can simply raise concerns if they believe actions should be taken to prevent future deaths.  

Families often hope organisations will act on these reports, only to find they haven’t. The Chief Coroner stresses that coroners are judges, not regulators, and unfortunately do not hold the power to enforce that any changes be made.  

Another implementation is the Introduction of the Statutory medical examiners scheme and a new death certification system. 

This reform implemented a new robust system of examination, meaning that all natural deaths now undergo mandatory scrutiny by a medical examiner, while non-natural deaths remain under coroner investigation. 

An issue that received attention was the need to work towards greater consistency of standards between coroner’s jurisdictions, to ensure fair and standardised treatment of all matters in England and Wales. Whether families will feel as though an inquest runs smoothly should not be based on a ‘postcode lottery’. Disparities have been found to lead to a worrying variety of quality of service from one coroner’s court to the next.  

Examples of measures put in place to achieve this include:  

• The Bench book: To achieve consistency of standards, a ‘Bench book’ was published in 2025, covering all aspects of inquest work to act as a guide for coroners. The guidance acts as a central resource for both coroners and the public to help locate key principles, practical information and precedents when dealing with inquests.  

• Re-appointment of regional leadership coordinators: The purpose of these appointments is to ensure better consistency and parity. Those appointed will aim to increase better regional cooperation. 

• Out of hours coroner’s service: the Chief Coroner is of the opinion that a coroner area should provide an out-of-hours service, including weekends and bank holidays. He also aims to create a rota system in all coroner areas and increase awareness of what an out of hours service should provide.

A long-term aim of the Ministry of Justice has been to reduce the number of coroner areas to a total of 75. Mergers are intended to provide a more consistent, standardised and effective service to the bereaved. The number of coroner areas was reduced to 74 by July 2025. 

Funding for judge-led inquests remains unresolved, as the government has no formal policy to provide centralised funding for this. The costs falls on local authorities and impacts routine services. 

As mentioned, the Chief Coroner remains committed to scrutinising the number of cases that take over 12 months to conclude. To help with this, each area will be asked to provide a number of cases that are anticipated to be categorised as long-duration cases.  

The Chief Coroner remains committed to working collaboratively with government departments, local authorities, and coroners to address these challenges. 

It reassuring that the Chief Coroner is alert to the issues the coronial system is facing and taking proactive steps to tackle them. The improvements flowing from this review will help to ensure that the needs of the bereaved are better met, which is vital as the coronial process is inevitably emotionally challenging for those who sadly find themselves involved in it.