On 16 July 2015 the second annual report from the Chief Coroner was published, revealing priorities for the forthcoming year and useful insights into the last 12 months.

The key points from the report which impact on healthcare organisations and their involvement with inquests are:  

  1. National consistency - the Chief Coroner has confirmed a commitment to achieving national consistency through guidance, training and discussion with coroners and stakeholders to bring a nationally unified approach to the service.
  2. Consolidation of services – the Chief Coroner has commented that coroners’ officers are often spread out, distant in location from the coroner they assist. Therefore, with a view to achieving a more effective and resilient coroner service at a local level, the Chief Coroner has encouraged bringing coronial services together under one roof.
  3. Inquests - slight reduction in the number of jury inquests. It is likely that this is linked to the changes introduced by the Coroners and Justice Act 2009, and the removal of the requirement to summon a jury for deaths in custody or otherwise in state detention, when the individual has died of natural causes.
  4. Focus on prison deaths - official statistics show that numbers of self-inflicted deaths in custody are particularly high, especially amongst those recently admitted. The Chief Coroner noted that coroners investigate all of these cases thoroughly and often make reports to prevent future deaths. The Chief Coroner held a one-day training day for coroners in May 2015 on deaths in prison.
  5. Higher volumes of inquests following the Chief Coroner’s Guidance No. 16. - the guidance concluded that those who die while subject to a Deprivation of Liberty Safeguards authorisation have died in ‘state detention’ so must be investigated (with an inquest) under section 1(2)(c) of the Coroners and Justice Act 2009. The Law Commission is considering the impact of these provisions on the coronial service (amongst other matters), and the Chief Coroner has confirmed that he will be participating in the consultation.
  6. Substantial increase in the number of cases being completed within a year - following the Chief Coroner’s requirement for senior coroners to produce an annual return of all outstanding cases over 12 months, the number of cases not completed within this time has now fallen by 45%. Backlog cases now represent less than 1% of all deaths referred to coroners in England and Wales. 
  7. Reduction in cases which require investigation - the introduction of the distinction between preliminary inquiries and formal investigation, along with the ability to discontinue an investigation in certain circumstances, has led to the earlier sign off of many cases that do not require investigation. This has consequently reduced the number of inquests across England and Wales by 15%.
  8. Setting dates – the Chief Coroner has reaffirmed the duty to set dates for inquests and pre-inquest reviews at the opening of an inquest, which can cause problems when healthcare professionals are called to give evidence at the inquest which has been scheduled for a date and time that they are not available.
  9. Prevention of Future Deaths reports - 504 Prevention of Future Death reports have been issued since publication of the first annual report last year.
  10. Recommended law changes – the Chief Coroner has recommended that there needs to be changes in the law by way of an amendment to section 13 of the Coroners Act 1988 (as amended). Section 13 currently allows the High Court to quash an inquest and order a new one, but some cases only require a change to the record of an inquest. For example, where the deceased was unknown at the time of the inquest but is later identified. Under current law, a fresh inquest would have to be ordered.

The full report can be accessed here.

The Chief Coroner concludes his report with much positivity surrounding progress made across England and Wales. Commitment to reforms has remained strong, particularly towards the provision of a nationally consistent approach, with training, guidance, advice, encouragement and support.