Nearly all inquests are held by a coroner sitting alone, without a jury. A jury must be summoned if the senior coroner has reason to suspect: Those which resulted in verdicts of murder or manslaughter (including many that would now be regarded as misadventure) are normally found in the indictments or depositions files of the relevant circuit. Statistics on deaths in prison custody are also published by her Majesty’s Prison and Probation Service (previously the National Offender Management Service, NOMS), accessible via the following link:

www.legislation.gov.uk/ukpga/2009/25/contents www.legislation.gov.uk/2013?title=coroners 1.2 Covid-19 deaths and Coroner statistics

The sex of the deceased is based on the ‘registrable particulars’ which coroners have a duty to record. Deaths certificates only gives two options, ‘male’ and ‘female’, and these will normally be completed by the registrar based on the information given to them by the informant. Under normal circumstances there would not be an investigation to ascertain whether what the informant says corresponds to biological sex or DNA of the deceased. ↩ There was a 13% increase in Treasure finds [footnote 19] reported in 2021 and a 2% increase in inquest conclusions into finds In 2021, the number of unclassified conclusions increased by 1,572 cases (up 24%) to 8,125. Unclassified conclusions made up 25% of all inquest conclusions in 2021, an increase in proportion by four percentage points compared to the 2020 amount. The rise in unclassified conclusions seen until 2014 and again from 2016 is partly due to the increasing use of what are known as ‘narrative conclusions’ by some coroners. In these cases, the conclusion is recorded as unclassified. As well as narrative conclusions, this category includes short non-standard conclusions which a coroner or jury might return when the circumstances do not easily fit any of the standard conclusions [footnote 9]. The number of registered deaths in England and Wales had been broadly increasing, from a low of 484,367 in 2011 to 541,589 in 2018. 2019, however, saw a decrease to 530,857, before rising to 607,922 in 2020 – the highest level in absolute terms, due to the Covid-19 pandemic. ONS provisional figures for 2021 show a decrease to 586,213. The number of deaths reported to coroners initially followed a similar trend, from a low of 222,371 in 2011 and then rising to a high of 241,211 in 2016. However, deaths reported to coroners over the last five years fell (there was a decrease in both deaths registered and deaths reported in 2019 and 2021), as shown in figure 1. This shows a reversal to similar broadly stable levels seen prior to 2015.

The remainder was forwarded to the King’s Bench. As London and Middlesex were anomalous jurisdictions without assize courts, their inquisitions were not treated in the same way. Coroners faced an unprecedented challenge at the height of the pandemic in 2020 with many complex inquests halted. Jury inquests resumed in 2021, as social distancing and other restrictions came to an end. Compared to 2020, there was a 79% increase in these inquests, but this still fell short of the 5-year pre-pandemic average by 14%. Coroners carried out post-mortem examinations on 43% of all cases reported to them.

The average time for an inquest to be conducted is estimated in the following way: coroners are asked in their annual return to state how many inquests were concluded within certain time periods. There are five time bands, which are: within one month; 1-3 months; 3-6 months; 6-12 months; and over 12 months. All the inquests falling within a time-band are then assumed to have been completed at or near the mid-point of the various time-bands for the purposes of calculating the average. However, inquests within the “under one month” band are assumed to have taken 3 weeks for the purpose of this estimation, and those inquests taking over a year to conclude are deemed to have taken 18 months, although the time-band itself is open-ended. Numbers are then aggregated and the average figure (in weeks) calculated in the normal way. The Coroner Service: Government Response to the Committee’s First Report - Justice Committee - House of Commons (parliament.uk) ↩ Conclusions recorded in 2020 may relate to deaths from 2020 or earlier years. It is not possible to follow the flow of cases through the system due to the way the data is collected. 2.6 Suspension of investigation / adjournment of inquest In 2021, 32,322 inquest conclusions were recorded, up 4% on 2020. Inquest conclusions of accident/misadventure, suicide and unclassified conclusions were up 2%, 8% and 24% on 2020 to 7,696, 4,820 and 8,126 respectively. When looking at the number of deaths reported to coroners in 2021 as a proportion of registered deaths [footnote 21], which allow for some differences in population characteristics, there is still a wide variation across coroner areas, with a minimum of 16% in North Yorkshire (Western) compared to the maximum of 82% in Newcastle upon Tyne. However, caution should be taken when using these figures as local area factors can influence these proportions. For example, large hospitals near boundary lines can impact the proportion, due to the difference between the coroners’ figures being based on the place of death and the ONS figures being based on the place of residence.