More data on death: Chief Coroner’s annual report for 2023

POSTED BY CLAIRE BRIDGMAN | 23 JULY 2024

| 3 min read

The Chief Coroner’s annual report covers the work of the coroner service in England and Wales 2023. His Honour Judge Teague KC’s report provides a comprehensive overview of all the work taken forward across the coroner service. It provides valuable insights into the service’s operations and future direction.

The Chief Coroner has described 2023 as a difficult year for the coronial service owing to difficulties in many areas still struggling with backlogs (which had built up during the COVID-19 pandemic) and changes to medical practice, leading to greater numbers of natural deaths being reported to coroners. Alongside this, the Chief Coroner attributes many coronial difficulties to the financial crisis severely affecting the ability of many local authorities and police services to appropriately resource coroner services. “Under funding of the service remains a serious and pervasive problem” according to His Honour Judge Thomas Teague KC.

Inquests are becoming increasingly legally complex

The Chief Coroner finds that anecdotal evidence, corroborated, in part, by statistics from the Ministry of Justice, suggests that the additional pressure on the coroner service, experienced since 2020, is not likely to be temporary. He concludes that the number of deaths being reported are rising and will continue to do so, and the complexity of coronial investigations is on the increase. This is in line with comments made recently by one of his senior coroners in Staffordshire.

Case complexity is anecdotally commonly reported now, and the Chief Coroner’s report reflects that feeling. Here, the Chief Coroner states that there is increasing pressure on coroners to provide greater explanations around deaths, particularly in healthcare settings, meaning coroners are dealing with more factually complicated deaths and greater volumes of material to consider. There is also reportedly increasing pressure from Interested Persons calling for coroners to engage Article 2 for inquests, and to push for the process to become more contentious.

He does, however, use his report to outline some positive developments in the past year, including a change in perception in how a coroner’s status as a judge is becoming more widely recognised; he details some of the media coverage which has been produced this year to assist in this. Coroners are also now being included in judicial initiatives including the One Judiciary project, and the Judges’ Council accepted its first coroner as a member last summer.

It's likely that public bodies will feel the knock-on effect of the pressure felt by coroners and will in practice see a push to clear backlogs and continue to manage increasingly complex cases in a sensitive manner. Public bodies may turn to legal support from lawyers to navigate an increasingly complex factual, medical and legal landscape, particularly if bereaved families and loved ones do so too.
A rise of PFD reports

The Chief Coroner highlights that in 2023 550 Prevention of Future Deaths (PFD) reports were issued, which is an increase of 132 compared with 2022. He takes the opportunity to also remind the reader that PFD reports should be ancillary to the inquisitorial process, should always have a foundation upon the evidence available to the coroner during the scope of the investigation and can only highlight risks; PFD reports should not contain remedial recommendations.

On a practical level, the Chief Coroner has for all reports published since 1 January 2023, uploaded them on to webpages which can make the text fully searchable. The idea being to facilitate analysis and identification of themes and thus benefit public learning.

He also talks about how coroners are coming under increased pressure to monitor responses to PFD reports. He explains, however, that once a PFD report is issued the coroner becomes “functus officio” meaning that they have no legal power to take further steps. Recipients of PFD reports have 56 days within which to respond (or request an extension to respond) in which they can respond by explaining why they won’t be actioning the coroner’s recommendations within a PFD report, or explaining the steps they have taken. There is, however, clearly a lack of enforcement mechanisms to oversee responses which, according to the Chief Coroner, often means a lack of response provided at all to PFD reports.
Variation in available resources

The Chief Coroner, within his “extraordinary report”, deals with numerous findings from his tour of all coroner areas this year. He opens his findings with:

“In all but a handful of areas, teams of coroners’ officers are understaffed and overworked, resulting in avoidable delays to cases and conspicuous lack of resilience, as well as adversely affecting officers’ welfare” and “the consistent picture across England and Wales is that staffing levels are far too low.”

He also found a dramatic contrast between court and office accommodation, security and general resourcing of materials between coroner areas, and no correlation with differing needs and caseloads. He goes on to list certain issues which caused him concern including the use of dilapidated buildings (leaks, mould and no disabled access), insensitively sited accommodation (sharing locations with birth registry, in open plan offices with no partitions or exposed to interruption by applause due to members of the public celebrating civil weddings), and finally the lack of dedicated courtrooms. This all contributes to inefficiency in an already stretched system and additional distress to bereaved families.

The Chief Coroner mentions on numerous occasions the need to “rebalance” the ration of fee paid to salaried coroners and as such identifies the need to employ more area coroners, to avoid the excessive over reliance on assistant coroners he has found in most areas.

The question will be where the funding will come from to remedy the resourcing issue. If resourcing can be rectified, then we're likely to see the backlog of cases cleared more quickly and sensitively, which in turn could put further pressure on public bodies involved in inquests as interested persons.
Judge-led inquests

During 2023 the Chief Coroner explains that there were three “judge-led inquests” being unusual inquests whereby a judge is borrowed from another jurisdiction. These are normally arranged by virtue of particularly complex or high-profile cases, when a coroner area is felt not to have the judicial resources to conduct the inquest in question.

The Chief Coroner is concerned about the funding model for such judge-led inquests. For example, the inquests into the deaths of patients treated by Ian Paterson will take years of investigation before conclusion. The cost of these investigations falls to the Local Authorities responsible for funding the coroner area that has jurisdiction over the deaths in question. There is currently no central funding readily available (or indeed a formal policy to deal with central funding) and as such this often falls with the Local Authority in question to bear the cost, which can have a detrimental knock-on effect on that area conducting its more routine coronial work.
Coroner service in the media

The Chief Coroner takes the opportunity to cover the work that has been done over the year to improve public understanding of the coroner service using various media outlets. He mentions the “Cause of Death” series on Channel 5, a Times interviews in July 2023 and a public livestreamed lecture in November 2023.

Future changes

Medical examiner system

One of the most significant areas of work for the Chief Coroner during 2023 was advising the Government about the impact on the coroner service of the forthcoming implementation of the statutory medical examiner scheme. The Draft Certificate of Cause of Death Regulations were published on 14 December 2023 and implementation is expected in 2024.

He describes how the Regulations will, in his view, provide a more principled distinction between medical certification and judicial certification and provide a more structured distinction in relation to corresponding duties for each side. This will inevitably lead to what the Chief Coroner describes as “wide-ranging changes to coronial processes.”

The introduction of the medical examiner has already started to contribute to the rise in the complexity of cases before coroners, with the Chief Coroner explaining that “complex cases where reportable factors might previously have been missed are now being identified and reported to coroners for investigation”.

Law changes

Other changes the Chief Coroner would like to see include:

Enabling the High Court, in appropriate circumstances, to be able to amend the Record of Inquest without ordering a fresh inquest when it quashes an inquest.
Power for a coroner to apply to the High Court without needing to first seek authority from the Attorney General to quash an inquest and hold a fresh investigation (eg where further evidence has come to light).
Enabling a British Sign Language interpreter to assist deaf jurors serving on an inquest jury, in line with provisions already in place (section 196 Police, Crime, Sentencing and Courts Act 2022 for jurors in the criminal or civil Court cases).
Clarifying statutory arrangements for the provision of coroner’s officers and other staff, this would be an amendment to section 24 of the 2009 Act.
Holding treasure inquests in writing. Currently, section 9c of the 2009 Act allows for the coroner to hold a non-contentious inquest in writing, subject to certain conditions, however this only applies to death investigations. Treasure inquests are still governed by the Coroner’s Act 1988 and Coroners Rules 1984. The Chief Coroner would like treasure inquests to be held in writing.
Putting coroners’ oath on statutory footing. It is currently set out in guidance, but coroners are not currently bound to take the judicial oath.
Enabling retired Circuit Judges to be nominated to conduct judge-led inquests. Currently, only a sitting circuit judge can conduct an investigation into a person’s death.

You can read the Chief Coroner’s annual report 2023 here.

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Claire Bridgman

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Claire Bridgman

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More data on death: Chief Coroner’s annual report for 2023

Future changes

Medical examiner system

Law changes

Our content explained

Further reading

CQC’s bulletin reviewed: four changes coming down the track

Claire Bridgman

Contact Claire Bridgman

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