Coroners Statistics 2010 England and Wales Ministry of Justice Statistics bulletin 

## Coroners Statistics 2010 England And Wales

 Ministry of Justice Statistics bulletin Also available on the Ministry of Justice website at http://www.justice.gov.uk/publications/statistics-and-data/coroners-andburials/deaths.htm 

## Executive Summary

This bulletin presents statistics of coroners' work during the calendar year 2010, including deaths reported, post-mortems, and inquests (including those for treasure and treasure trove).  These figures are used to monitor coroners' workload, throughput of cases, and percentages of post-mortems and inquests. In previous years this report was entitled "Statistics on deaths reported to coroners, England and Wales, (year)". 

## Main Points

- Some 230,600 deaths were reported to coroners in 2010, a rise of 700 
(0.3 per cent) from the 2009 figure. *(Tables 1,2, and 3)* 
- The proportion of all registered deaths reported to coroners remained at 
an estimated1 47 per cent in 2010, the same as in 2009.  This 
percentage has been relatively consistent over for the last few years. (Table 2) 
- The percentage of cases involving post-mortem examinations, as a 
proportion of all deaths reported to coroners, fell slightly from just below  
46 per cent in 2009 to 44 per cent in 2010, continuing the existing downward trend.  *(Table 3)* 
- Inquests were opened on 31,000 deaths, representing over 13 per cent 
of all deaths reported to coroners, the same proportion as in 2009. (Table 3) 
- As in recent years, the most common verdicts returned at inquests were 
death from natural causes (in 29 per cent of cases) and death by 
accident or misadventure (28 per cent).  *(Tables 4 and 6)* 
- Verdicts of suicide fell by two per cent in 2010 compared to the previous 
year; there were also falls in the number of verdicts of death from 
industrial disease, from accident or misadventure, and open verdicts.  
There was a rise of 400, or 10 per cent, in the number of non-specific 
verdicts, a category which includes narrative verdicts which are a factual record of how and in what circumstances the death occurred; often used 
where the cause of death does not easily fit any of the standard verdicts. (Table 6) 
- The estimated2 average time taken to process an inquest in 2010 
(defined as being from the time the death was reported until the conclusion of the inquest, where the death occurred in England and Wales) was 27 weeks, the same as in 2009.  *(Table 7)* 
                                           
 

## Introduction

This bulletin presents statistics of deaths reported to coroners in England and Wales in 2010 in accordance with section 28 of the Coroners Act 1988.  
Information is provided on deaths reported to coroners, post-mortem examinations and inquests held, and verdicts returned at inquests.  The data are collected via statistical returns completed by coroners.  In previous years this report was entitled "Statistics on deaths reported to coroners, England and Wales, (year)". 

## Background

In England and Wales, coroners are required by law to hold an inquest into violent, unnatural, sudden deaths of unknown cause, and those deaths which occur in prison or police custody.  When investigating a death, it is the coroner's duty to establish who the deceased was, and how, when and where the deceased came by his or her death.  At the close of an inquest, coroners (or juries if they have been summoned) are required to return a verdict covering these questions and to certify the verdict in an inquisition. In the majority of deaths reported to them, however, coroners' investigations are concluded without an inquest being held. The coroner will have satisfied himself or herself, by means of a post-mortem examination or other investigation, on the physical cause of death, and that the death was not one on which he or she is required by law to hold an inquest. Verdicts are returned in nearly all inquests.  The exceptions are inquests adjourned by the coroner if, for example, criminal proceedings take place. The inquest is usually not resumed because the relevant evidence has been heard elsewhere.  Nearly all inquests are held by a coroner sitting alone, without a jury, but a jury must be summoned in some circumstances, for example where the death occurred in prison or police custody. 

A coroner may request that a post-mortem be conducted, whether or not an inquest is held, particularly if the cause of death is not clear.  In many cases a post-mortem examination may take place in order to determine whether or not an inquest is necessary. In England and Wales a coroner also handles investigations regarding finds reported to them under the provisions of the Treasure Act.  The coroner will inquire into any treasure which is found in their districts and to establish who were the finders. These statistical bulletins are available from the Ministry of Justice website at http://www.justice.gov.uk/publications/statistics-and-data/coroners-andburials/deaths.htm. 

The **Explanatory Notes** section at the end of this report provides brief definitions for some of the terms used in this report, information about statistical revisions, and the symbols and conventions used. 

If you have any feedback, questions or requests for further information about this statistics bulletin, please direct them to the appropriate contact given at the end of this report. 

## Quality And Consistency Of The Statistics

Every effort is made to ensure that the figures presented in this publication are accurate and complete.  Although care is taken in collating and analysing the returns used to compile these figures, the data are of necessity subject to the inaccuracies inherent in any large-scale collection of this type. Returns are individually quality-assured and validated in a process that highlights inconsistencies between years, and other areas.  Checks are made to ensure that each return is arithmetically correct, including with subtotals and grand totals correctly summed.  Unusual values encountered in a return are queried with the data supplier, to confirm whether these are correct, or an error in the information provided which requires amendment. The Explanatory Notes section provides further information on the quality and consistency of these statistics.  

## Related Statistics

All deaths in England and Wales must be registered with the Registrar of Births and Deaths.  For those deaths where a coroner conducts an inquest, the death will be registered at the conclusion of the inquest, and the cause of death classified according to the verdict returned by the coroner. Statistics on registered deaths in England and Wales are published by the Office for National Statistics (ONS) in their series on mortality statistics. These can be accessed from the ONS website at http://www.statistics.gov.uk/StatBase/Product.asp?vlnk=15096 
The Ministry of Justice's coroner statistics differ from ONS figures because they count two different, albeit related, events. The Ministry of Justice's coroner statistics provide the number of deaths which are reported to coroners in England and Wales. These include deaths reported to coroners which occurred outside England and Wales.  ONS's mortality statistics, based on death registrations, report the number of deaths registered (irrespective of whether a coroner has investigated) in England and Wales in a particular year.  ONS figures do not include deaths that occurred outside England and Wales. The proportion of deaths which are reported to coroners has been estimated using death registration figures published by ONS. Estimates for 2010 have been calculated using ONS's monthly provisional figures on death registrations, while estimates for 2009 and earlier years have been calculated using final annual death registration figures for the relevant year. 

## Deaths Reported (Tables 1, 2 And 3, Figures 1 And 2)

The number of deaths reported to coroners in 2010 rose by 700 (0.3 per cent) from the previous year, from 229,900 in 2009 to 230,600 during 2010, reflecting the slight rise in the number of deaths registered in England and Wales.  The proportion of registered deaths in the calendar year 2010 that were reported to coroners in 2010 remained at an estimated 47 per cent, the same level as in 2009.  This percentage has been relatively consistent for the last few years.  Of these reported deaths, around 2,000 (less than one per cent) were reports of deaths that had occurred outside England and Wales. 

and Wales, 1950-2010 Figure 1: Registered deaths, and deaths reported to coroners, England and Wales, 1950-2010
Figure 1: Registere Figure 1: Registered deaths, and deaths reported to coroners, England and Wales, 1950-2010Figure 1: Registered deaths, and deaths reported to coroners, England and Wales, 1950-2010
Figure 1: Registered  deaths, and deaths reported to coroners, England and Wales, 1950-2010Figure 1: Registered deaths, and deaths reported to coroners, England and Wales, 1950-2010
 
NOTE: The figures for deaths reported to coroners in the columns to the right of the vertical dashed line include no further action (NFA) cases, while those to the left exclude NFA 
cases (see Explanatory Notes for more information about NFA cases). The long-term trends of both the number and proportion of deaths reported have generally been upwards.  In the most recent few years, however, the increase in the proportion has become shallower than previously, while the number of deaths reported has been generally flat, albeit with some fluctuations, partly reflecting the actual number of registered deaths in any one year.   
Since the Shipman murders came to light over a decade ago, there has been more concern about proper process.  In the longer term, the rise in the number of deaths reported to coroners is probably also due in part to the growing use, over at least the last twenty years, of deputising services by general practitioners, leading to a greater number of referrals to coroners. 

ta en rc pe a s a rs ne o r
    Figure 2: Deaths reported to coroners as a percentage of registered deaths, England and Wales, 1996-2010
g e o f re g ist e red dea ths, Eng land and Wal es, 
1996
-201
0

## Post-Mortem Examinations Held And Inquests Opened (Tables 1, 2, And 3, Figures 3A And 3B)

Post-mortem examinations were ordered by coroners in 44 per cent of all cases reported to them in 2010, a fall compared to 2009, and continuing the existing downward trend. 

 d NOTE: this graph of e ag nt shows the proportion of all deaths referred to coroners where a post-mortem examination took place, whether there was an inquest or not. 

ce er p
   Figure 3a: Post-mortems as a percentage of deaths reported to coroners, England and Wales, 1996-2010
e ath s re p ort e d t o co rone rs, Engl and and Wale s, 1
996-
2010
 
The actual number of deaths reported to coroners in 2010 where a postmortem was held was 101,900, some 3,400 fewer than in the year before, despite the overall increase in reported deaths. 

Inquests were opened on 30,800 deaths reported to coroners in 2010, 200 fewer than in 2009.  Inquest cases represented more than 13 per cent of all the deaths reported to coroners in 2010, a similar proportion of the total as in the previous year. 

       Figure 3b: Inquests as a percentage of deaths reported to coroners, England and Wales, 1996-2010
eath s re port ed t o co rone rs, Engl and and Wale s, 1 996- 2010

## Post-Mortems In Inquest Cases (Table 3)

When an inquest is held a post-mortem examination has usually been conducted, and in 2010 post-mortems were conducted in 89 per cent of such cases.  This is a lower proportion than in the previous year by around 2 percentage points, and continues a shallow declining trend over the past decade or so.  Prior to the late 1990s, the holding of an inquest without a post-mortem examination was comparatively rare, accounting for around 2 
per cent or less of inquest cases every year.  In 2010 there were nearly 
3,400 inquests without a post-mortem, around four and a half times the number so reported ten years ago. 

## Post-Mortems In Non-Inquest Cases (Table 3)

In the majority of cases referred to coroners there is no inquest.  In 2010, there were some 75,000 non-inquest cases where a post-mortem was held, and the percentage of non-inquest cases that required a post-mortem fell to just above 37 per cent.  This proportion has fallen steadily in recent years; in 
1995 it was 56 per cent of all non-inquest cases.   

## Cases Requiring Neither An Inquest Nor A Post-Mortem (Table 3)

There were also 125,000 cases reported to coroners where there was neither an inquest nor a post-mortem.  This particular category of case has generally been increasing in number in recent years.  In addition, the percentage of cases where there was neither an inquest nor a post-mortem examination has increased, as a proportion of all coroners' cases, from around 40 per cent or just above in the late 1990s, to 54 per cent in 2010. 

## Inquest Verdicts Returned (Tables 4, 5 And 6, Figures 4, 5 And 6)

Verdicts were returned at some 29,400 inquests in 2010, nearly 400 less than in 2009.  As in previous years the most common verdicts in 2010 were  
death from natural causes (8,400, 29 per cent), and death by accident or misadventure (8,100, 28 per cent of all verdicts).  Unclassified verdicts, which category includes narrative verdicts, represented 14 per cent of the total, and verdicts of suicide comprised 11 per cent in 2010. 

For the first time in 2010, verdicts of death from natural causes were the most frequently recorded.  The category to see the largest rise in 2010 was unclassified (including narrative) verdicts, which were up 10 per cent, from 
3,800 in 2009 to 4,200 in 2010. There were decreases in the numbers of verdicts in many categories over the past year, mainly reflecting the overall drop in the numbers of inquests concluded by a verdict.  These included:  

- A 15 per cent drop in verdicts of deaths from dependence on drugs 
or non-dependent abuse of drugs, from 570 to 480; 
- a 6 per cent drop in the number of verdicts of death by accident or 
misadventure (down from 8,700 to 8,100); 
- a 6 per cent drop in the number of open verdicts (down from 2,200 to 
2,100). 
The rise in unclassified verdicts is at least in part due to the increasing use of what are known as 'narrative verdicts' by some coroners (see the paragraph on trends, below).  A narrative verdict is where, instead of a conventional verdict, at the end of the inquest the coroner records a factual record of how and in what circumstances the death occurred.  Recent case law may be responsible for the increased number of narrative verdicts in recent years, including the House of Lords Middleton3 judgement which encouraged their use. 

## Trends (Table 5 And Figure 4)

Verdicts of death from natural causes are tending to rise steadily, and there is also a steady and steeper rise in the number of unclassified, including narrative, verdicts.  There is a long-term slight downward trend in the numbers of verdicts of suicide, though there are fluctuations within that trend. As a *proportion* of verdicts delivered by coroners during a calendar year, there are five main trends, two rising, and three falling: 
                                           
 

- verdicts of death from natural causes have risen steadily from 13 per 
cent in 1996 to around 29 per cent in 2010; 
- unclassified verdicts (which include narrative verdicts, as explained 
above) formed less than one per cent of the total up to and including 
2001, but accounted for around one in every seven verdicts in 2010; 
- verdicts of death by accident or misadventure have been declining 
steadily, from 47 per cent of verdicts returned in 1996 to 28 per cent in 2010; 
- suicide verdicts have been declining slowly over the same period, from 
17 per cent in 1996 to around 11 per cent in 2010; 
- open verdicts have been falling in percentage terms in the last few 
years, from around 11 per cent in the mid-1990s to 7 per cent in 2010. 
Figure 4: Verdicts returned at inquests, England and Wales, 1996-2010Figure 4: Verdicts returned at inquests, England and Wales, 1996-2010 Figure 4: Verdicts returned at inquests, England and Wales, 1996-2010Figure 4: Verdicts returned at inquests, England and Wales, 1996-2010 Figure 4: V erdicts returned at inquests, England and Wales, 1996-2010Figure 4: Verdicts returned at inquests, England and Wales, 1996-2010 Figure 4: Verdicts returned at inquests, England and Wales, 1996-2010Figure 4: Verdicts returned at inquests, England and Wales, 1996-2010 Figure 4: Verdicts returned at inquests, England and Wales, 1996-2010
       Figure 4: Verdicts returned at inquests, England and Wales, 1996-2010
 
*Includes open verdicts, and non-specific verdicts, etc. (see Table 6) 

## Gender Differences (Table 4, Figures 5 And 6)

The pattern of verdicts differs between males and females.  Male deaths accounted for about 69 per cent of all verdicts returned in 2009; but they also included: 

- 92 per cent of verdicts of death from industrial disease; - 78 per cent of verdicts of suicide, and - 82 per cent of verdicts of death from dependence on, or nondependent abuse of, drugs.   
For females, the most common verdicts were: 

- death by accident or misadventure (32 per cent of all female 
verdicts), and 
- death from natural causes (also 32 per cent).   
These proportions were all similar to those in recent years.  Females also accounted for a relatively high percentage of unclassified or narrative verdicts (39 per cent). 

2010 Figure 5: Verdicts returned at inquests by sex, England and Wales, 2010
es, 2010Figure 5: Verdicts returned at inquests by sex, England and Wales, 2010
urned at inquests by sex, England and Wales, 2010Figure 5: Verdicts returned at inquests by sex, England and Wales, 2010
       Figure 6: Number of verdicts returned at inquests, by sex, England and Wales, 2010

## Age Of Deceased In Inquests Where A Verdict Was Returned (Table 5)

From 2008, coroners were asked to provide information (in summary form) 
on the ages of persons whose deaths proceeded to inquest and a verdict returned during the year.  Over 45 per cent of completed inquests in 2010 
were on persons who were 65 years of age or more at death.  Less than nine per cent of inquests concluded were into deaths of persons aged under 
25. 

## Inquests With Juries, And Adjourned Inquests (Table 7)

Nearly all inquests concluded in 2010, as in other years, were held without juries.  The number of inquests held with juries in 2010 was 440 (representing just under one and a half per cent of all inquests), a modest fall of about 20 compared to 2009.  Both the number and proportion of inquests held with juries have shown a downward trend in recent years; the proportion of inquests held with juries has fallen from 3.6 per cent of inquests concluded in 1999 to less than 1.5 per cent in 2010. 

Around 1,000 inquests were adjourned by the coroner under Section 16 of the Coroners Act 1988 because criminal proceedings took place, and subsequently were not resumed.  This is comparable with the level generally prevailing in recent years. 

## Time Taken To Process An Inquest (Table 7)

The estimated average time taken to process an inquest in 2010 (defined as being from the time the death was reported until the conclusion of the inquest) was 27 weeks to the nearest whole week, the same as in 2009, but  
slightly longer than in 2007 and 2008.   
2010 Figure 6a: Estimated average time taken to process an inquest, 2004-2010
to process an inquest, 2004-2010Figure 6a: Estimated average time taken to process an inquest, 2004-2010
 E a: 6 re gu i F

stim
     ated
            ave
                rage  tim
                           e ta
                                 ken 

 

This period has slightly increased since the present system of estimating 
this average was introduced in 2004, when it was 22 weeks.  Only deaths 
occurring within England and Wales are included in this estimation.  More 
information about how the average has been estimated can be found in the 
Explanatory Notes section. 
 

## Treasure And Treasure Trove (Table 8 And Figure 7)

On 24 September 1997, the Treasure Act 1996 came into force and replaced the common law of Treasure Trove in England and Wales.  The 
1996 Act introduced new requirements for reporting and dealing with finds. Not all finds need be the subject of an inquest. In 2010, 623 finds were reported and 362 inquests were concluded, from which a verdict declaring a find to be Treasure was returned in 318 cases. There were no inquests held into Treasure Trove in 2010 (relating to finds made before the current Act came into force), but it is likely that a few such inquests will continue to be held for some time. 

The number of finds reported has been steadily increasing in recent years– this is probably because of the increasing popularity of treasure-hunting as a hobby.  The dip in reported finds in 2001 is almost certainly due to the foot-and-mouth outbreak, which severely restricted access to land during the spring of that year. An annual report on the operation of the Treasure Act 1996 is published by the Department for Culture, Media and Sport. 

est nqu d i an ers ron Fi 
 

## Tables

Table 1.  
Deaths reported to coroners, 2010 
Table 2. 
Registered deaths, deaths reported to coroners, and inquests 
opened, 1950-2010 
Table 3. 
Deaths reported to coroners, post-mortem examinations held 
and inquests opened, 1996-2010 
Table 4. 
Inquest verdicts returned, 2010 
Table 5. 
Age of deceased in inquests where a verdict was returned, 
2010 
Table 6. 
Inquest verdicts returned, 1996-2010 
Table 7. 
Inquests concluded which were held with juries and inquests 
adjourned; High Court orders and exhumations, 1996-2010 
Table 8. 
Treasure inquests, 1996-2010 
Table 9. 
Reported deaths, post-mortems and inquests by jurisdiction, 
2010, and comparison with 2009 
Table 10. 
Inquest verdicts returned, by jurisdiction, 2010 Map 
Coroner districts in England and Wales as at 31 December, 
2010 
 
Table 1Table 1 Table 1Table 1 Table 1Table 1
Table 7Table 7Table 7

ntinued
Table 9 conti
nue
Table 10 continued
Table 10 c
ontinued
Table 10 continued
Table 10 cont
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e
dTable 10 continued
Table 10 continued
Table 10 continued
Table 10 continued
Table 10 conti
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e
d
Table 10 continued
Table 10 
c
on
t
i
n
u
edTable 10 continued
Table 10 continued
Tabl
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 1
0
 c
o
nt
inu
edTable 10 continued

## Map Of Coroner Jurisdictions In England And Wales During 2010 (See Below For Key To Jurisdictions)

 

## Key To Jurisdictions

North East 
101 - Darlington and South Durham 102 - North Durham 103 - Hartlepool 104 - North Northumberland 105 - South Northumberland 106 - Teesside 107 - Gateshead and South Tyneside 108 - Newcastle upon Tyne 
109 - North Tyneside 110 - Sunderland North West 
201 - Cheshire 203 - South and East Cumbria 204 - North and West Cumbria 205 - Manchester (city) 206 - Manchester North 

London 
701 - City of London [not visible] 702 - East London 703 - Inner London North 
704 - Inner London South 705 - Inner London West 706 - North London 707 - South London 708 - West London 
South East 
801 - Berkshire 
802 - Brighton and Hove 
803 - Buckinghamshire 804 - East Sussex 
805 - Central Hampshire 
806 - North East Hampshire 807 - Portsmouth and South East Hampshire 808 - Southampton and New Forest 809 - Isle of Wight 810 - Central and South East Kent 811 - Mid Kent and Medway 812 - North East Kent 813 - North West Kent 814 - Milton Keynes 815 - Oxfordshire 816 - Surrey 817 - West Sussex 
South West 
901 - Avon 902 - Cornwall 903 - Exeter and Greater Devon 904 - Plymouth and South West Devon 905 - Torbay and South Devon 906 - Bournemouth and Eastern Dorset 907 - Western Dorset 
908 - Gloucestershire 909 - Isles of Scilly 910 - Eastern Somerset 911 - Western Somerset 912 - Wiltshire and Swindon 
Wales 1001 - Bridgend and Glamorgan Valleys 1002 - Cardiff and Vale of Glamorgan 1003 - Carmarthenshire 1004 - Central North Wales 1005 - Ceredigion 1006 - Gwent 1007 - Neath and Port Talbot 1008 - North East Wales 1009 - North West Wales 1010 - Pembrokeshire 1011 - Powys 1012 - City and County of Swansea 

North West (continued) 
207 - Manchester South 208 - Manchester West 209 - Blackburn, Hyndburn and Ribble Valley 
210 - Blackpool and Fylde 211 - East Lancashire 212 - Preston and West Lancashire 213 - Sefton, Knowsley and St Helens 214 - Liverpool 215 - Wirral Yorkshire and the Humber 
301 - East Riding and Hull 302 - North Lincolnshire and Grimsby 303 - York City 
304 - North Yorkshire - East 
305 - North Yorkshire - West 306 - South Yorkshire - East 307 - South Yorkshire - West 308 - West Yorkshire - East 309 - West Yorkshire - West East Midlands 
401 - Derby and South Derbyshire 402 - North Derbyshire 403 - Leicester and South Leicestershire 404 - North Leicestershire and Rutland 405 - Boston and Spalding 406 - West Lincolnshire 407 - Spilsby and Louth 408 - Stamford 409 - Northamptonshire 410 - Nottinghamshire West Midlands 
501 - Herefordshire 502 - North Shropshire 
503 - South Shropshire 504 - Staffordshire South 505 - Stoke-on-Trent and North Staffordshire 506 - Telford and Wrekin 507 - Warwickshire 508 - Birmingham and Solihull 509 - Black Country 510 - Coventry 511 - Wolverhampton 512 - Worcestershire East of England 
601 - Bedfordshire and Luton 602 - North and East Cambridgeshire 603 - South and West Cambridgeshire 604 - Essex and Thurrock 605 - Hertfordshire 607 - Norfolk 609 - Peterborough 610 - Southend on Sea 611 - Suffolk 
 

## Explanatory Notes

1. The United Kingdom Statistics Authority has designated these statistics 
as National Statistics, in accordance with the Statistics and Registration 
Service Act 2007 and signifying compliance with the Code of Practice for Official Statistics. 
Designation can be broadly interpreted to mean that the statistics: 

- 
meet identified user needs; 
- 
are well explained and readily accessible; 
- 
are produced according to sound methods, and 
- 
are managed impartially and objectively in the public interest. 
Once statistics have been designated as National Statistics it is a statutory requirement that the Code of Practice shall continue to be observed. 

ted as National Statistics it is a statutory requirement that the Code of Practice shall continue to be observed. 

2. The data analysed in this publication are based on annual returns from 
H.M. Coroners.  Coroners are required under the provisions of Section 28 of the Coroners Act 1988 to furnish to the Secretary of State returns 
in relation to inquests held and deaths inquired into by him (or her) in such form and containing such particulars as the Secretary of State may direct.  Thanks are due to coroners and their staff for their work in 
preparing these returns. 
2. The data analysed in this publication are based on annual returns from 
H.M. Coroners.  Coroners are required under the provisions of Section 
28 of the Coroners Act 1988 to furnish to the Secretary of State returns 
in relation to inquests held and deaths inquired into by him (or her) in such form and containing such particulars as the Secretary of State may direct.  Thanks are due to coroners and their staff for their work in 
preparing these returns. 

## Definitions Definitions

The following brief definitions are intended as a guide to the meaning of terms in this bulletin concerning coroners and their work; more detailed definitions will be found in the Coroners Act 1988 and the Treasure Act 
1996. 

The following brief definitions are intended as a guide to the meaning of terms in this bulletin concerning coroners and their work; more detailed definitions will be found in the Coroners Act 1988 and the Treasure Act 
1996. 

## Coroner; Deaths Reported Coroner; Deaths Reported

In England and Wales, all violent and unnatural deaths, sudden deaths of unknown cause, and all deaths of persons in custody, are reported to coroners.  Coroners are appointed by local authorities; they must be barristers, solicitors or registered medical practitioners and must have at least five years' standing in the relevant profession.  The relevant legislation and guidance is contained within the Coroners Act 1988 and the Coroners Rules 1984 (S.I 1984/552 and subsequent amendments).  A link to the Act is here: http://www.legislation.gov.uk/ukpga/1988/13/contents The more recent amendments to the Coroners Rules may be found at: http://www.legislation.gov.uk/   (home page) 

## Non-Inquest Cases

The coroner's investigation is concluded most often without an inquest being held.  The coroner will have satisfied himself or herself, by means of a postmortem examination or other investigation, on the physical cause of death, and that the death was not one on which he or she is required by law to hold an inquest. 

## Post Mortem Examinations

A coroner may request that a post-mortem examination be conducted, whether or not an inquest is held, particularly if the cause of death is not clear.  In many cases a post-mortem examination is conducted in order to determine whether or not an inquest is necessary.  Other post-mortem examinations are held which are not ordered by the coroner.  Details of these are collected by the Office for National Statistics (ONS).  See the further information section below for details of how to obtain statistics on this and other related topics. 

## Inquests

A coroner must hold an inquest if the body of a person ('the deceased') lies within his or her district4 and if he or she has reasonable cause to suspect that the deceased: (a) died a violent or unnatural death; (b) died a sudden death the cause of which is unknown; or (c) died in prison or in such place or in such circumstances as to require an inquest under any other Act. The holding of an inquest requires the coroner to determine: (a) who the deceased was; (b) how, when and where the deceased came by his or her death, and any further particulars necessary to enable the death to be registered. 

Verdicts are returned in nearly all coroners' inquests.  The exceptions are those inquests adjourned by the coroner which he or she later decides not to resume, and are mainly inquests into deaths by unlawful killing and deaths by dangerous driving or careless driving when under the influence of alcohol or drugs, in which court proceedings have been instituted.  This avoids the need for two tribunals to consider the same evidence.  A 
"narrative verdict" is where the coroner makes a brief and factual statement at the conclusion of the inquest but does not return one of the suggested short-form verdicts. 

## Timeliness Of Inquests

For the purpose of determining the timeliness of inquests, 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 verdict or (b) the day the coroner certifies that an adjourned inquest will not be resumed.  
                                            
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, although inquests within the "under one month" band are assumed to have taken 3 weeks for this purpose of this estimation, and those inquests taking over a year to conclude were 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.   
Only deaths occurring within England and Wales are included in the calculation.  Statistics are not collected on the time taken for inquests where the death occurred outside England and Wales.  Deaths occurring abroad are often significantly delayed because of the difficulty, for example, of obtaining reports from other countries.   

## Juries

Nearly all inquests are held by a coroner sitting alone, without a jury.  A jury must be summoned where the death occurred: (a) in prison, or in such a place or such circumstances as to require an inquest under another Act; (b) in police custody, or resulted from an injury caused by a police officer in the purported execution of his or her duty; (c) where there are certain statutory reporting obligations under the Health and Safety Act 1974 or any other Act, and in certain other circumstances, especially where there may be a continuing or recurring danger to the public. 

## Treasure And Treasure Trove

In addition to inquiring into certain deaths, coroners also have jurisdiction to inquire into any treasure which is found in their districts and to establish who were the finders.  With the commencement of the Treasure Act 1996 on 24 
September 1997 inquests into finds which previously might have been declared treasure trove are supplemented by those now conducted to determine whether finds made on or after that date are treasure. 

## Registered Deaths

All deaths in England and Wales must be registered with the Registrar of Births and Deaths.  The term 'registered deaths' in this bulletin refers to deaths registered within a specific time period (in this case, calendar years). Statistics on registered deaths in England and Wales are published by the ONS in their series on mortality statistics.  At the time of going to press, final  
figures had not been published for the number of registered deaths in 2010, but a provisional figure has been derived from the monthly registration figures which are published by ONS at regular intervals.  

## Quality And Consistency Of The Statistics

The figures presented in this report are collected via statistical returns completed by coroners.  The process by which coroners provide their returns can vary according to the case management system they use.  
Many coroners use a system provided by an external contractor, while other coroners use alternative computer systems or a paper-based system. Although care is taken in completing, analysing and quality-assuring the data provided on the statistical returns, the figures are, of necessity, subject to possible inaccuracies inherent in any large-scale collection of this type. For this reason, figures may not be accurate to the final digit.  In the text, numbers have been rounded, usually to the nearest 100, although some smaller figures may be given exactly. 

Coroners are independent office-holders, and there is considerable variation in the way each coroner's district is structured and managed, and in the mechanisms they have in place for discharging their duties under the Coroners Act.  From a statistical perspective one of these differences relates to the way they approach the handling of "NFA" cases. Many deaths referred to coroners require no further action being taken by them - these are known as "NFA" cases.  These are deaths reported to coroners where there was no inquest, no post-mortem, and no certificate was issued by the coroner for registration or any other purpose.  The statistics for 1995 onwards include all NFA cases within the figures for deaths reported that required neither an inquest nor a post-mortem.  Prior to 1995, however, some coroners did not report some or all of their NFA cases in their annual statistics (figures for some earlier years are shown in Table 
2), and the inclusion of all NFA cases in the statistics addressed this inconsistency in reporting. Despite the inclusion of all NFA cases in the statistics since 1995 however, there may still be some differences between coroners as to which cases they consider constitute a substantive "reported death" (and are therefore reported in their statistics) where little or no action is required on their part and no post-mortem or inquest is held.  As such, the statistics reflect those cases which each individual coroner considers to be a death reported to them, and the figures for different coroner districts can be compared on this basis. 

## Uses Of The Statistics

The main users of these statistics are coroners themselves, and Ministers and officials in central government responsible for developing policy with regard to coroners.  Other users include local authorities (who are responsible for the appointment and remuneration of coroners), other central government departments, and those non-governmental bodies, including various voluntary organisations, with an interest in coroners and inquests. The statistics are used to monitor the volume and types of cases dealt with by coroners in England and Wales each year. 

## Revisions To Statistics For Previous Years

The estimated figure for the number of registered deaths in 2009 which was derived for the purposes of Table 2 in last year's edition of this bulletin has now been replaced by an actual figure subsequently published by the Office for National Statistics. The figure for the estimated average time to process an inquest in 2009 reported in Table 7 has been revised.  After the publication of the  2009 statistics in May 2010, one coroner revised the timeliness statistics for their completed inquests in 2009, which had the effect of altering (due to rounding) the overall national estimated average inquest timeliness in Table 7 from 26 weeks to 27. 

## Symbols And Conventions

The following symbols have been used throughout the tables in this bulletin: 
n/a    = Not applicable - 
= Nil 

.. 
= Not available 

* 
= Percentage not shown due to being based on small numbers 
of cases 
(R)  
= Revised data 

## Further Notes

Prior to 1 June 2005, policy responsibility for H.M. Coroners lay with the Home Office, but on that date it passed to the Department for Constitutional Affairs as part of machinery of government changes following the 2005 general election.  Responsibility now lies with the Ministry of Justice, which was created on 9 May 2007. Prior to the transfer of responsibility, the Home Office published statistical bulletins based on coroners' annual returns, from 1980.  The last four bulletins published in the Home Office Statistical Bulletin series were as follows: for year 2003, bulletin 9/04; for 2002, bulletin 6/03; for 2001, bulletin 3/02; and for year 2000, bulletin 7/01.  These may be found at: 
http://homeoffice.gov.uk/science-research/research-statistics. 

Previous editions of this bulletin published by the Ministry of Justice, the Department for Constitutional Affairs, and the Home Office, were entitled "Statistics on deaths reported to coroners, England and Wales, (year)". 

Further information on deaths occurring annually in England and Wales is published by the Office for National Statistics in their Mortality Statistics series; these may be downloaded from their website at www.statistics.gov.uk. 

## Contact Points For Further Information

Current and previous editions of this publication are available for download at http://www.justice.gov.uk/publications/statistics-and-data/coroners-andburials/deaths.htm   A spreadsheet file of the statistics tables in this bulletin are also available for download from this address. Press enquiries should be directed to the Ministry of Justice press office: 
Tel: 020 3334 3573 
Email: andrew.chiles@justice.gsi.gov.uk Other enquiries about these statistics should be directed to: 
Richard Allen Ministry of Justice 7th Floor (7.20) 
102 Petty France London SW1H 9AJ Tel: 020 3334 3737 
Email: statistics.enquiries@justice.gsi.gov.uk A copy of the data collection form which was sent to coroners can be obtained via the contact details above. The Department for Culture, Media and Sport's annual reports on the Treasure Act 1996 may be found on their website: www.culture.gov.uk. 

General enquiries about the statistical work of the Ministry of Justice can be e-mailed to: statistics.enquiries@justice.gsi.gov.uk. 

Other National Statistics publications, and general information about the official statistics system of the UK, are available from www.statistics.gov.uk. 

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