Coronial statistics 2019

26 May 2020

Amidst the Coronavirus news, updates and briefings, the Coroner’s statistics for 2019 in England and Wales have now been published. The annual Coroner’s Statistics bulletin presents statistics on deaths reported to Coroners, post-mortem examinations and inquests held, and conclusions recorded at inquests in England and Wales.The data spans the period of January to December 2019 and so is not affected by Covid-19 deaths. It will be interesting in time to see the data for 2020 and how that compares to this most recent 2019 publication.

There are a number of main points that the publication highlights, which I have set out below. The publication itself can be found here, and goes into more depth and statistical analysis of the featured highlights. Additionally, some of the more interesting points have been elaborated on below.

Main points:

  • The number of deaths reported to Coroners in 2019 was the lowest it has been since 1998, and is down 4% from 2018.
  • The proportion of registered deaths in England and Wales reported to Coroners has decreased by 1%.
    • In 2019 40% of all registered deaths were reported.
  • The deaths reported in state detention are 7% lower than they were in 2018, with 478 deaths in state detention reported to the Coroners in 2019.
  • The number of inquests opened in 2019 (compared to 2018) increased by 3%.
  • Post-mortem examinations were carried out on 39% of all deaths reported in 2019, which remains relatively stable.
    • In 2019, 59% of inquest cases involved a post-mortem.
  • In 2019, 31,300 conclusions were recorded in total, which is an increase of 2% from 2018.
    • Suicide and unclassified conclusions were the main drivers in the increase, as both increased from 2018.
  • The average time taken to process an inquest has risen by a week since 2018.
    • The average time taken to process an inquest in 2019 was 27 weeks.

Inquest conclusions

At the end of an inquest, the Coroner (or jury if applicable) completes a form entitled ‘Record of an inquest’. This form documents the ‘conclusion’ of the Coroner or jury as to who died and how, when, and where they died.

Conclusions are recorded in nearly all cases that proceed to inquest, and can take the short form or narrative. The exceptions are those inquests adjourned, and not resumed, by the Coroner under Schedule 1 to the 2009 Act because criminal proceedings have taken place.

The published statistics provide some interesting facts about the conclusions having been made in 2019 in relation to gender, age and common conclusions.

The pattern of conclusions recorded differs between males and females. Male deaths accounted for 65% of all conclusions recorded in 2019 while female deaths accounted for 35%. Male deaths accounted for 56% of deaths reported. However male deaths accounted for 65% of all conclusions recorded in 2019. This suggests that males are more likely to die in circumstances that lead to an inquest.

Of the inquests completed in 2019, 53% related to persons who were aged 65 years or over at time of death compared with 6% related to persons under 25 years of age.

In 2019 the most common short form conclusions (in frequency) were death by misadventure (25% of all conclusions), suicide (15%) and death by natural causes (13%). Unclassified conclusions (which include narrative verdicts) made up 20% of all inquest conclusions in 2019. This reflects the Chief Coroner’s guidance that wherever possible Coroners should conclude with a short-form conclusion.

Time taken to process an inquest

For the purpose of determining the average time taken to complete an inquest, the time taken to conduct an inquest is deemed to be from the day the death was reported to the Coroner until either (a) the day the inquest is concluded by the delivery of a conclusion or (b) the day the Coroner certifies that an adjourned inquest will not be resumed.

The estimated average time taken to process an inquest in 2019 was 27 weeks. This is an increase of one week compared to 2018, but is still within the 6 months required under Rule 8 of the Coroners (Inquest) Rules 2013.

The time taken to process an inquest varies by Coronial jurisdiction, and it was found that the maximum average time taken to process an inquest in 2019 was 50 weeks in City of London, and the minimum average time was eight weeks in North Tyneside.

Deaths in state detention

In 2019 deaths in state detention reported to Coroners decreased by 7%, and it is expected that this is due to a fall in number of deaths of individuals in prison custody and detained under the Mental Health Act 1983 (as amended).

The number of deaths in prison custody decreased by 5% when compared to 2018. For detailed information on the impact of COVID-19 on secure estates, please click here.


The statistics are published yearly, and usually compare themselves to the year previously, or any particular year of significance, such as when it has been lowest or highest percentage in some time. The statistics will undoubtedly be quite significantly different when published this time next year, in 2020, considering the impact the current COVID-19 situation has had, and the significant delays that will have a knock on effect from nearly all inquests having been removed from the court diaries for both the past few months, and near future.


Holly Paterson, solicitor, BLM 

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Disclaimer: This document does not present a complete or comprehensive statement of the law, nor does it constitute legal advice. It is intended only to highlight issues that may be of interest to clients of BLM. Specialist legal advice should always be sought in any particular case.

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