Legal Update: Annual Coroners statistics indicate downward trend in reported deaths and Inquests in 2017

This Ministry of Justice’s annual report 2017 presents statistics on deaths reported to coroners in England and Wales including post-mortem examinations and inquests held, and recorded conclusions at inquests.

A summary of those findings is as follows:-

  • 5% drop in deaths reported
  • 8% drop in deaths reported in state detention
  • 66% drop in DoLS deaths reported
  • 1% drop in reported deaths requiring a post-mortem examination
  • 18% drop in the number of inquests opened
  • 16% drop in inquest conclusions

Deaths Reported

The fall in the number of deaths reported to coroners, the lowest level since 2014, is largely explained by the amendment to the Coroners and Justice Act 2009 – with effect from 3 April 2017 an individual subject to a DoLS authorisation is no longer considered to be ‘otherwise in state detention’ thus removing the requirement to report DoLS deaths to the coroner where the death is one of natural causes. 57% of registered deaths in 2017 were not reported.

Deaths in State Detention

Since 2015, the inclusion of DoLS deaths within the figures for reported deaths in state detention has distorted the long term trend. It is interesting to note that as a consequence of the change in the law the number of reported deaths in state detention dropped by 63% in 2017 compared to the previous year. Taking DoLS deaths out of the equation, the drop in reported deaths in state detention in 2017 has been driven by a fall in the number of deaths of individuals detained under the Mental Health Act 1983, thus reversing the steady increase since 2011.

Post-mortem Examinations Held

Post-mortem examinations were carried out on 37% of all deaths reported in 2017 – which represents a modest 1% drop from 2016. Interestingly, the proportion of deaths in which a post-mortem examination was required steadily decreased from 61% in 1995 to 37% in 2017.

Of the 85,552 post-mortems conducted in 2017, the vast majority (approx. 72%) did not require an inquest which suggests that the post-mortem findings indicated a natural cause of death. It is not surprising therefore that the value of traditional autopsy as the standard mode of post-mortem investigation has come into question. Recent research has concluded that improvements in post-mortem CT scanning (PMCT) techniques mean it should now be considered a safe and reliable substitute for invasive autopsy.

The 2017 coroner’s statistics demonstrate a notable increase in post-mortems conducted using less invasive techniques such as PMCT – 1671 in 2017 compared to 764 the previous year. In 2017, 56 of the 89 coroner areas had carried out at least one non-invasive post-mortem with the Black Country and South Yorkshire (Western) having conducted over 25% of post-mortems using less-invasive techniques.  The increased use of PMCT has been driven by requests by families whose objection to an invasive post-mortem is often based on religious tenets. See Chief Coroner’s guidance.

Inquests Opened

The 18% drop in inquests opened reflects the removal of the requirement to report DoLS deaths to coroners – all such cases previously requiring an inquest. The number of inquests opened in 2017 is the lowest since 2014, the last reporting year before DoLS investigation requirements were introduced.

Inquest Conclusions

The 16% fall in the number of inquest conclusions reflects the fall in the number of inquests opened, which has fallen due to the removal of the requirement to investigate deaths under DoLS from April 2017 onwards. A conclusion of natural causes or death by accident/misadventure accounted for 49% of the short form conclusions in 2017. In 2015 and 2016 there had been a significant increase in the number of natural causes conclusions driven by the number of DoLS death in respect of which 94% of the inquest conclusions were natural causes.  Consequently there was a 43% drop in natural causes conclusions in 2017 which reflects this.

Deaths Reported to Coroners as a Proportion of Registered Deaths

The number of deaths reported to coroners as a proportion of registered deaths varies widely across coroner areas. This is not surprising given that large hospitals within the boundary lines of a coroner area will impact on the proportion of reported deaths – coroners figures are based on the place of death not the deceased’s place of residence. Whereas ONS figures for registered deaths are based on place of residence. The report notes that in the coroner area of Newcastle upon Tyne the number of deaths reported to the coroner as a proportion of registered deaths in the area was a substantial 79%. Whereas, in nearby Hartlepool it was 24%. This no doubt reflects the existence of a large hospitals Trust in the Newcastle area which take referrals from across the region.


It is clear that the removal, in April 2017, of the requirement for coroners to investigate all DoLS deaths has had a significant impact on the trends derived from the 2017 coroners statistics. It is also interesting to see that coroners are showing an increased willingness to utilise, in appropriate cases, innovative PMCT techniques in place of traditional autopsy – in the coming years we anticipate that this upward trend will continue as confidence in the reliability of PMCT findings grows.


Partner in Sintons Healthcare Team

If you have any questions or require any advice on the issues discussed in this article please contact Kathryn Riddell on: (0191) 2267829 or

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