Coroners Statistics – England and Wales, 2012
Source: data.gov.uk (2018-05-25)

Coroners Statistics. This annual bulletin presents statistics on the workload of coroners in England and Wales. Information is provided on the number of deaths reported to coroners, post-mortem examinations and inquests held and conclusions recorded at inquests. It also covers treasure finds reported to coroners, treasure inquests held under the Treasure Act, and proportion of treasure verdicts returned. The data are collected via annual statistical returns completed by coroners.

Data on deaths reported to the coroner are available by gender, age (of deceased with an inquest conclusion recorded) and coroner area. Information is also available on deaths in state detention (including those individuals subject Deprivation of Liberty orders), inquest conclusions and deaths abroad.

Coroners Statistics 2012 
 
 
Coroners Statistics 2012 
England and Wales 
 
Ministry of Justice 
Statistics bulletin  
 
 
 
 
Published 16 May 2013 
 

Coroners Statistics 2012 
 
2

Coroners Statistics 2012 
Contents 
Executive Summary 
4 
Introduction 
5 
Deaths reported 
9 
Post-mortem examinations held and inquests opened 
11 
Inquest verdicts returned 
15 
Treasure and Treasure Trove 
21 
Map 7 
Coroner districts in England and Wales, 2012 
23 
Annex A: Analysis of Unclassified verdicts 
25 
Explanatory notes 
34 
Glossary 
37 
Contacts 
40 
 
 
3

Coroners Statistics 2012 
Executive Summary 
This bulletin presents statistics of coroners’ work during the calendar year 
2012, 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)”.  
 Some 227,721 deaths were reported to coroners in 2012, an increase of 
5,350 (two per cent) from the 2011 figure. 
 The proportion of all registered deaths reported to coroners was an 
estimated 46 per cent in 2012, the same as in 2011.  Over the last five 
years this proportion has been relatively consistent, within the range 46 to 
47 per cent. 
 The estimated average time taken to process an inquest in 2012 (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 26 weeks, 
slightly less than the last three years’ figure of 27 weeks.  The maximum 
time taken to process an inquest in 2012 was 53 weeks, and the minimum 
time was eight weeks. 
 Verdicts of suicide rose by one per cent in 2012 compared to 2011, from 
3,471 to 3,515. 
 Also rising were the number of unclassified verdicts, a category which 
includes narrative verdicts, which are a factual record of how and in what 
circumstances the death occurred, often returned where the cause of 
death does not easily fit any of the standard short-form verdicts. 
 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 (26 per cent). 
 
4

Coroners Statistics 2012 
Introduction 
This annual bulletin presents statistics of deaths reported to coroners in 
England and Wales in 2012 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)”. For previous editions of this report please see:  
www.gov.uk/government/publications/coroners-statistics-ns 
This publication should be read alongside the statistical tables which 
accompany it, also found via the link above. 
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 death occurred.  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 (the written record of the inquest). 
In the majority (86 per cent) of deaths reported to them, however, coroners’ 
investigations are concluded without an inquest being held. The coroner will 
have satisfied themselves, 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 (97 per cent).  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 (98 per cent) 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. 
Figure 1 shows the possible outcomes involved when a death is reported to a 
coroner. 
 
5

Coroners Statistics 2012 
Figure 1: Deaths reported to coroners, 20121 
Deaths registered in
England and Wales
 
*Provisional ONS figure 
In England and Wales a coroner also handles investigations regarding finds 
reported to them under the provisions of the Treasure Act 1996.  The coroner 
will inquire into any treasure which is found in their districts and establish who 
the finders were. 
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. 
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 
                                            
1 This covers events during 2012, for example the verdicts in 2012 may relate to cases from 
2012 or earlier years.  It is not possible to follow the flow of cases through the system due to 
the way the data is collected. 
(499,326) ONS
Deaths not repor ed 
t
to coroner  
s
(271,605) 
Deaths reported
to coroners
(227,721)
Deaths abroad 
(1,741) 
Inquest held
(32,542)
No Inquest 
(inc NFAs )
(195,113) 
 
Verdicts 
(30,123)
Post Mortem
(94,814)
Inquest Adjourned and 
Not Resumed (943) 
No Post Mortem 
(132,841) 
Average time to process an inquest 
(26 weeks)
Deaths registered in
England and Wales
(499,326) ONS*
Deaths abroad 
(1,766) 
Deaths not repor ed 
t
to coroner  
Deaths reported
s
(271,605) 
to coroners
(227,721)
No Post Mortem 
(132,907) 
Post Mortem
(94,814)
No Inquest  
Inquest opened
NFAs 
(32,542)
(inc 
)
(195,179) 
 
Inquest Adjourned and  
Average time to process an inquest 
(26 weeks)
Not Resumed (943) 
Verdicts recorded at inquest
(30,123)
 
6

Coroners Statistics 2012 
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:  
www.statistics.gov.uk/hub/population/deaths/mortality-rates/index.html 
For annual summary of monthly figures please see: 
www.ons.gov.uk/ons/rel/vsob2/monthly-figures-on-deaths-registered-by-area-
of-usual-residence--england-and-wales/index.html 
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.  The ONS’ 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, and therefore do not include deaths that occurred outside England and 
Wales. 
The proportion of deaths which are reported to coroners has been estimated2 
using death registration figures published by ONS. Estimates for 2012 have 
been calculated using ONS' monthly provisional figures on death registrations, 
while percentages for 2011 and earlier years have been calculated using final 
annual death registration figures for the relevant year. 
For the first time this publication includes figures for deaths which occurred in 
state custody.  Statistics on deaths in prison custody are also published by 
NOMS, accessible via the following link: 
www.gov.uk/government/publications/safety-in-custody 
The figures for deaths in custody in this publication relate only to those deaths 
which have been reported to a coroner, whereas the NOMS publication 
includes all deaths which have occurred in prison custody and those which 
occurred whilst the offender was released on temporary licence (ROTL) for 
medical reasons. 
The Youth Justice Board also include figures for deaths of young people 
(under 18) in custody in the Youth Justice Statistics publication, accessible via 
the link below: 
www.gov.uk/government/publications/youth-justice-statistics 
                                            
2 Statistics on the number of registered deaths in England and Wales are published by the 
Office for National Statistics.  A final figure for the total number of registered deaths in 2012 
has not yet been published, so a provisional figure from ONS, derived from the monthly 
figures for death registrations in England and Wales, has been used. 
 
7

Coroners Statistics 2012 
For further information on criminal convictions of homicide please refer to 
Volume 5 of the Ministry of Justice publication Criminal Justice Statistics, 
available at the following link: 
www.gov.uk/government/organisations/ministry-of-justice/series/criminal-
justice-statistics 
The Criminal Justice Statistics publication includes figures on the number of 
prosecutions and convictions of homicide.  The Coroner Statistics publication 
records the number of verdicts of homicide recorded by coroners at inquests 
so these numbers are not directly comparable as the Criminal Justice 
Statistics covers all prosecutions and convictions for homicide, while the 
coroner data only covers cases where a verdict of homicide has been given at 
an inquest.
 
8

Coroners Statistics 2012 
Deaths reported 
The number of deaths reported to coroners in 2012 rose by 5,350 (two per 
cent) from the previous year, from 222,371 in 2011 to 227,721 during 2012, 
reflecting the increase in the number of deaths registered in England and 
Wales.  The proportion of registered deaths in the calendar year 2012 that 
were reported to coroners in 2012 was an estimated 46 per cent, the same as 
in 2011.  This percentage has shown a slight downward trend over the last 
few years. 
Map 1 below shows deaths reported in each coroner jurisdiction in 2012 as a 
percentage of the population. 
Map 1: Deaths reported to coroners as a percentage of the population, 
England and Wales, 2012 
 
 
9

Coroners Statistics 2012 
Figure 2: Registered deaths, and deaths reported to coroners, England 
and Wales, 2002-2012 
0
50
100
150
200
250
300
350
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Thousands of deaths
Registered deaths reported to coroners
Registered deaths not reported to coroners
Percentage of registered deaths reported to coroners
                                           
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
 
Over the last decade, the number of registered deaths has decreased from 
535,356 in 2002 to 499,3263 in 2012; however the number has fluctuated in 
recent years.  The number of deaths reported to coroners has stayed within 
the range of 222,371 and 234,784 over the last ten years, varying between 42 
and 47 per cent of registered deaths (see Table 2 in the statistical tables). 
 
3 Provisional figure based on ONS monthly death registration figures for 2012 
 10

Coroners Statistics 2012 
 
Post-mortem examinations held and inquests opened  
Post-mortem examinations were ordered by coroners in 42 per cent of all 
cases reported to them in 2012, a slight decrease compared to 2011, and 
continuing the existing downward trend (see Table 3).  Over the last ten years 
the percentage of post-mortems ordered has decreased by ten percentage 
points from 117,684 to 94,814. 
The actual number of deaths reported to coroners in 2012 where a post-
mortem was held was 94,814, some 860 more than in the previous year, 
reflecting in part the increase in the total number of reported deaths. 
Map 2: Post-mortems as a proportion of deaths reported to coroners, 
England and Wales, 2012 
 
 11

Coroners Statistics 2012 
Figure 3: Post-mortems and inquests as a percentage of deaths reported 
to coroners, England and Wales, 2002-2012 
0
10
20
30
40
50
60
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Percentage of deaths reported
Post-mortems as a percentage of deaths reported to coroners
Inquests as a percentage of deaths reported to coroners
 
Inquests were opened on 32,542 deaths reported to coroners in 2012, an 
increase of 1,561 on 2011.  Inquest cases represented 14 per cent of all the 
deaths reported to coroners in 2012, a small increase, and continuing a long-
term rising trend.  Over the last ten years the percentage of inquest cases has 
increased by three percentage points. 
Map 3: Inquests held as a proportion of deaths reported to coroners, 
England and Wales, 2012 
 
 12

Coroners Statistics 2012 
Post-mortems in inquest cases  
When an inquest is held a post-mortem examination has usually been 
conducted, and in 2012 post-mortems were conducted in 87 per cent of such 
cases.  This is a lower proportion than in the previous year by one percentage 
point, and continues a shallow declining trend over the past decade.  Prior to 
the late 1990s, the holding of an inquest without a post-mortem examination 
was comparatively rare, accounting for around two per cent or less of inquest 
cases every year.  In 2012 there were 4,263 inquests without a post-mortem 
representing 13 per cent of inquests, this is over three times the number 
reported ten years ago. 
Post-mortems in non-inquest cases  
In the majority (86 per cent) of cases referred to coroners there is no inquest.  
In 2012, there were 66,535 non-inquest cases where a post-mortem was held, 
and the percentage of non-inquest cases that required a post-mortem fell to 
34 per cent.  This proportion has fallen steadily in recent years; in 2002 it was 
47 per cent of all non-inquest cases. 
Cases requiring neither an inquest nor a post-mortem 
There were also 128,578 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 2002 there were 106,248 such 
cases).  In addition, the percentage of cases where there was neither an 
inquest nor a post-mortem examination has increased, as a proportion of all 
deaths reported to coroners, from around 47 per cent in 2002, to 56 per cent 
in 2012. 
Post-mortem rates, histology4 and toxicology5  
Post-mortems can be classed as either standard or non-standard, depending 
on the cost of the examination.  A non-standard post-mortem is charged at a 
higher rate than a standard post-mortem and is defined as a post-mortem 
which requires special skills.  A non-standard post-mortem could, for example, 
require a paediatric or specialist pathologist.  In 2012, 95 per cent of post-
mortems were ordered at a standard rate, a slight decrease compared to 96 
per cent in 2011 (see Table 4). 
In 2012, 18,700 post-mortems included histology (20 per cent of post-
mortems held), which was 750 more than in 2011, an increase of one 
percentage point.  12,613 post-mortems held in 2012 included toxicology (13 
per cent of post-mortems held), the same percentage as in 2011. 
                                            
4 Histology in the context of post-mortems is the examination of tissues under a microscope. 
5 Toxicology in the context of post-mortems is the study of body fluids and tissues for the 
detection of drugs. 
 13

Coroners Statistics 2012 
Out of England Orders  
Every person who wishes to remove a body of a deceased person out of 
England and Wales must give notice of such intention to the coroner within 
whose jurisdiction the body is lying. When the coroner gives permission for 
the removal of the body an Out of England order is issued. 
Coroners issued 5,030 Out of England orders in 2012, compared with 5,008 
issued in 2011.  In both years the number of orders issued represented just 
over two per cent of the total number of deaths reported to coroners (see 
Table 5). 
Of the 227,721 deaths reported to coroners in 2012, some 1,766 (less than 
one per cent) were reports of deaths that had occurred outside England and 
Wales, the same percentage reported in 2011. 
Deaths in Custody 
In 2012 a total of 281 deaths were reported to coroners which occurred in 
state custody6; less than one per cent of the total number of deaths reported. 
The highest number (152 or 54 per cent of the total) occurred in Prison 
custody, followed by 93 (33 per cent) in Mental Health Act detention centres 
(see Table 6). 
                                            
6 This data only represents deaths in custody which were referred to a coroner. 
 14

Coroners Statistics 2012 
Inquest verdicts returned 
Verdicts were returned at 30,123 inquests in 2012, which was 265 more than 
in 2011.  As in previous years the most common verdicts in 2012 were death 
from natural causes (8,849, or 29 per cent), and death by accident or 
misadventure (7,705, or 26 per cent).  Unclassified verdicts, which include 
narrative verdicts, represented 15 per cent of the total, and verdicts of suicide 
comprised 12 per cent in 2012 (see Tables 7 and 9).  Map 4 shows the 
percentage of suicide verdicts in each coroner district. 
Map 4: Suicide verdicts as a proportion of all inquest verdicts, England 
and Wales, 2012 
 
In 2010, verdicts of death from natural causes for the first time became the 
most frequently recorded. This category was again the most frequent in 2011 
and 2012.  Unclassified verdicts saw the largest rise in terms of numbers; an 
increase of 234 (five per cent) from 4,400 in 2011 to 4,634 in 2012.  Because 
of the overall rise in the number of verdicts returned, there were rises in 
several categories. 
There were decreases in the numbers of verdicts in a few categories over the 
past year, which included a 34 per cent drop in verdicts of homicide (Killed 
lawfully or Killed unlawfully), from 237 to 1587. The number of verdicts of 
                                            
7 For information on criminal convictions of homicide please refer to the Criminal Justice 
System Statistics publication, available at www.gov.uk/government/organisations/ministry-of-
justice/series/criminal-justice-statistics  
 15

Coroners Statistics 2012 
death from non-dependent abuse of drugs dropped by 27 per cent (down from 
188 to 138), however this is effectively cancelled out by the 23 per cent 
increase in verdicts of death from dependence on drugs (up from 215 to 265). 
Figure 4: Verdicts returned at inquest, by category, England and Wales, 
2012 
Suicide
12%
Natural causes
29%
Unclassified
15%
All other verdicts*
1%
Open verdicts
7%
Accident or 
misadventure
26%
Industrial disease
9%
Drug related
1%
 
*Killed unlawfully, Killed lawfully, Attempted or self-induced abortion, Cause of death aggravated by lack of care, or 
self-neglect, Want of attention at birth, Stillborn, Disasters 
The rise in unclassified verdicts is 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.  As well as narrative verdicts, this category 
also includes short non-standard verdicts which a coroner or jury might return 
when the circumstances do not easily fit any of the standard verdicts. Please 
see Annex A for further analysis of narrative verdicts. 
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, and a 
more definite downward trend in the number of verdicts of accidental death. 
As a proportion of verdicts delivered by coroners during a calendar year, there 
are four main trends, two rising, and two falling: 
 verdicts of death from natural causes have risen steadily from 19 per cent 
in 2002 to more than 29 per cent in 2012; 
 16

Coroners Statistics 2012 
 unclassified verdicts (which include narrative verdicts, as explained above) 
formed two per cent of the total in 2002, but have since risen steadily to 
account for over 15 per cent of verdicts in 2012; 
 verdicts of death by accident or misadventure have been declining 
steadily, from 40 per cent of verdicts in 2002 to 26 per cent in 2012; 
 open verdicts have been declining over the same period, particularly over 
the last few years, they accounted for just under seven per cent of the total 
in 2012 compared with ten per cent in 2002. 
Figure 5: Number of verdicts returned at inquests, England and Wales, 
2002-2012 
0
2,000
4,000
6,000
8,000
10,000
12,000
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Number of verdicts
Deaths by accident or misadventure
Suicide
Deaths from industrial diseases
Deaths from natural causes
Unclassified
All other verdicts*
 
*Killed unlawfully, Killed lawfully, Attempted or self-induced abortion, Cause of death aggravated by lack of care, or 
self-neglect, Want of attention at birth, Stillborn, Disasters, Dependence on drugs, Non-dependent abuse of drugs, 
Open verdicts 
Differences in verdicts by sex 
The pattern of verdicts differs between males and females.  Male deaths 
accounted for about 67 per cent of all verdicts returned in 2012, however they 
accounted for 53 per cent of deaths reported; suggesting males are more 
likely to die in circumstances that lead to an inquest. Female deaths 
accounted for about 33 per cent of all verdicts returned in 2012 (and 47 per 
cent of deaths reported).  
 Of the 3,515 verdicts of suicide, 79 per cent were for males and 21 per 
cent for females 
 17

Coroners Statistics 2012 
 Of the 2,059 open verdicts, 71 per cent were for males and 29 per cent for 
females, and 
 36 per cent of the 8,849 verdicts of death from natural causes were for 
females, the remaining 64 per cent were for males. 
Figure 6: Verdicts returned at inquests by sex, England and Wales, 2012 
61%
79%
92%
64%
80%
71%
59%
67%
39%
21%
8%
36%
20%
29%
41%
33%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Accident or
misadventure
Suicide
Industrial
disease
Natural
causes
Drug-related
Open verdicts
All other
verdicts
Total verdicts
Percent of verdicts
Males %
Females %
 
0%
5%
10%
15%
20%
25%
30%
35%
Accident or
misadventure
Suicide
Industrial
disease
Natural causes
Drug-related
Open verdicts
All other
verdicts
Percent of verdicts
Males
Females
 
 18

Coroners Statistics 2012 
Age of deceased in inquests where a verdict was returned 
Since 2008, coroners have been asked to provide information (in summary 
form) on the ages of persons whose deaths proceeded to inquest and a 
verdict returned during the year.  Of the inquests completed in 2012, 48 per 
cent were on persons who were aged 65 years or over at death.  Less than 
eight per cent of inquests concluded were into deaths of persons aged under 
25 (see Table 8). 
Figure 7: Age of deceased in inquests where a verdict was returned, 
England and Wales, 2012 
45 to 64 years
65 years and over
15 to 24 years
Under 1 year
1 to 14 years
25 to 44 years
 
Inquests with juries, and adjourned inquests  
Nearly all inquests concluded in 2012, as in other years, were held without 
juries.  The number of inquests held with juries in 2012 was 472 (representing 
just two per cent of all inquests), and a decrease of 10 compared to 2011.  
Both the number and proportion of inquests held with juries showed a 
downward trend until recent years but the trend appears now to have halted, 
with the proportion remaining around two per cent for the last five years.  
Nevertheless, the proportion of inquests held with juries has fallen from three 
per cent of inquests concluded in 2002, to two per cent in 2012 (see Table 
10). 
Some 943 inquests (representing three per cent of all inquests concluded) 
were adjourned by the coroner under Section 168 of the Coroners Act 1988 
because criminal proceedings took place, and subsequently were not 
resumed.  This level is comparable to that generally prevailing in recent years. 
                                            
8 Section 16 of the Coroners Act 1988 states that the coroner should adjourn an inquest in the 
event of criminal proceedings. 
 19

Coroners Statistics 2012 
Time taken to process an inquest 
The estimated9 average time taken to process an inquest in 2012 (defined as 
being from the time the death was reported until the conclusion of the inquest) 
was 26 weeks to the nearest whole week (see Table 10). 
The average time taken has slightly increased since the present system of 
estimating this average was introduced in 2004, when it was 22 weeks, 
although it has decreased slightly from the 2011 average of 27 weeks.  Only 
deaths occurring within England and Wales are included in this estimation.  
More information about how the average time has been estimated can be 
found in the Explanatory Notes section. 
The maximum time taken to process an inquest in 2012 was 53 weeks, and 
the minimum time was eight weeks. The time taken has a relatively large 
range of 45 weeks, which could be due to the fact that coroners’ caseloads 
can vary greatly and a direct comparison is therefore not advised. 
Map 5: Average time taken to process inquests, England and Wales, 
2012 
 
                                            
9 A direct average of the time taken to process an inquest cannot be calculated from the data 
collected; an estimate has been made instead.  Please see Explanatory Notes for more 
information. 
 20

Coroners Statistics 2012 
Treasure and Treasure Trove 
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.  For more information please see; 
www.legislation.gov.uk/ukpga/1996/24/contents 
In 2012, 750 finds were reported and 355 inquests were concluded, from 
which a verdict declaring a find to be treasure was returned in 337 cases (see 
Table 11).  There were two inquests held into Treasure Trove in 2012 (relating 
to finds made before the current Act came into force), and it is likely that a few 
such inquests will continue to be held from time to time. 
The number of finds reported has been steadily increasing over the last ten 
years, although in 2012 there was a slight decrease of six per cent compared 
to 2011. 
The number of verdicts of treasure in 2012 was exactly the same as the 
number recorded in 2011 (337), however the proportion of treasure inquests 
which resulted in a verdict of treasure increased slightly, from 93 per cent in 
2011 to 95 per cent in 2012. 
An annual report on the operation of the Treasure Act 1996 is published by 
the Department for Culture, Media and Sport. For more information please 
see: 
www.gov.uk/government/organisations/department-for-culture-media-
sport/series/treasure-and-portable-antiquities-statistics 
 21

Coroners Statistics 2012 
Figure 8: Finds reported to coroners and inquests held under the 
Treasure Act, 2002-2012 
0
100
200
300
400
500
600
700
800
900
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Number of finds or inquests
Number of finds reported
Number of inquests held
 
Map 6: Number of treasure finds reported to coroners, England and 
Wales, 2012 
 22

Coroners Statistics 2012 
 23
Map 7 
Coroner districts in England and Wales, 2012 
 
Key to jurisdictions 
North East 
109 – North Tyneside 
101 – Darlington and South Durham  
110 – Sunderland 
102 – North Durham  
 
North West 
103 – Hartlepool  
104 – North Northumberland 
201 – Cheshire 
105 – South Northumberland 
203 – South and East Cumbria 
106 – Teesside 
204 – North and West Cumbria 
107 – Gateshead and South Tyneside 
205 – Manchester (city) 
108 – Newcastle upon Tyne 
206 – Manchester North 

Coroners Statistics 2012 
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 
406 – Central Lincolnshire 
408 – South Lincolnshire 
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 
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 
 
 
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 
 
 24

Coroners Statistics 2012 
Annex A: Analysis of Unclassified verdicts 
Summary 
This research aims at unpacking the reasons behind the rise of 1,477 in the 
“Unclassified verdicts” category over the last five years.  To investigate this 
increase we asked two independent assessors to analyse a random sample of 
2,196 “Unclassified verdicts” recorded between 2007 and 2011. 
The analysis shows that there is scope for introducing a new short-form 
category: “Medical or surgical intervention unsuccessful”.  This category 
accounts for around 25 per cent of the total (varying between 17 and 33 per 
cent). 
The analysis also shows a substantial agreement between the two 
independent assessors (Kappa coefficient of 0.61).  However, there could be 
tighter guidance on the definition of which verdicts belong to each short-form 
category – there was some disagreement on whether some verdicts were 
correctly classified. 
The paper also explored the hypothesis that suicide verdicts are ‘hidden’ 
within the “Unclassified verdicts” category.  The analysis showed that the 
overall percentage of “Could indicate suicide” verdicts within the “Unclassified 
verdicts” category is around six per cent. 
Introduction 
Coroners in England and Wales are required to submit at the end of each 
calendar year a statistical return to the MoJ, which includes the number of 
inquest verdicts returned, broken down by category of verdict.  In addition to 
the fourteen short-form categories10 there is a category for “Unclassified 
verdicts”, which includes narrative verdicts.  Narrative verdicts are where, at 
the end of the inquest instead of a conventional short-form verdict the coroner 
records a factual description of how and in what circumstances the death 
occurred. 
Coroners are requested to provide details of all “Unclassified verdicts” they 
have recorded on a supplementary sheet as part of their annual return; 
however this is not always provided, or is sometimes not provided in sufficient 
detail to explain the cause of death. 
                                            
10 The current short-form categories are: Killed unlawfully; Killed lawfully; Suicide; Attempted 
or self-induced abortion; Cause of death aggravated by lack of care, or self-neglect; 
Dependence on drugs; Non-dependent abuse of drugs; Want of attention at birth; Deaths 
from industrial diseases; Deaths by accident or misadventure; Stillborn; Deaths from natural 
causes; Open verdicts; Disasters. 
 25

Coroners Statistics 2012 
Since 2000, the number and percentage of “Unclassified verdicts” returned at 
inquests has been steadily increasing (see Figure A1).  In the last five years 
the number has increased from 2,923 in 2007 (11 per cent of total verdicts) to 
4,400 in 2011 (15 per cent of total verdicts). 
Figure A1: “Unclassified verdicts” as a percentage of all verdicts 
returned at inquests, England and Wales, 1995-2012 
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Percentage of total
 
Recent case law could be responsible for this increase in narrative verdicts, in 
particular the House of Lords judgement in R v HM Coroner for West 
Somerset ex parte Middleton in 2004, which encouraged their use.11 
Coroners are unable to record a short-form verdict of suicide unless they are 
convinced beyond any reasonable doubt that the deceased intended to take 
his/her own life.  This has caused concerns regarding the number of suicides 
which could potentially be ‘hidden’ in the “Unclassified verdicts” category. 
In 2011 the Office for National Statistics published a study entitled ‘Narrative 
verdicts and their impact on mortality statistics in England and Wales’.  The 
study was conducted as the ONS was ‘concerned about the impact of 
narrative verdicts on the quality of statistics on cause of death’12.  They 
concluded that: 
                                            
11 The Middleton case suggested that a narrative verdict could be used instead of a short-
form verdict, in order to provide information on the circumstances surrounding the death. The 
judgement can be found at the following link: 
www.publications.parliament.uk/pa/ld200304/ldjudgmt/jd040311/midd-1.htm 
12 ‘Narrative verdicts and their impact on mortality statistics in England and Wales’ in Health 
Statistics Quarterly 49, Spring 2011 (ONS) 
 26

Coroners Statistics 2012 
The increase in the use of narrative verdicts by coroners has not had a 
statistically significant impact on published suicide rates in England and 
Wales… A recommendation has been made to coroners to consider 
ways of recording narrative verdicts to allow more accurate coding of 
cause of death.13 
Following on from the Office for National Statistics’ study, we conducted this 
analysis for the period 2007 – 2011 in order to examine what verdicts are 
actually included in the “Unclassified verdicts” category, and whether, based 
on the findings, there is any scope for new guidance or changing the short-
form categories. 
Methodology 
We asked two independent assessors (in this case two retired coroners) to 
analyse a sample taken from the “Unclassified verdicts” category, for the 
years 2007 – 2011. The sample was determined using stratified sampling 
across all coroner districts. The size was determined to be around ten per 
cent of all “Unclassified verdicts” and it aimed at providing 95 per cent 
confidence intervals of around six percentage points width.  This means that 
the size was around 450 verdicts each year. 
To obtain our sample we randomly selected verdicts from the “Unclassified 
verdicts” list provided by each coroner district14. The sample verdicts were 
then categorised independently by the assessors into one of six groups: 
1. Could indicate suicide – i.e. a verdict which implies the deceased took 
his/her own life 
2. Indicates alcohol abuse (with or without other factors) 
3. Medical or surgical intervention unsuccessful 
4. Error – verdict should be in one of the existing short-form categories (in 
this case the assessor was asked to provide a description of which 
category the verdict should, in his opinion, be placed in) 
5. Correct – verdict could not be in any other category 
6. Unknown – insufficient data is provided to determine cause of death 
The first category was chosen due to the existing hypothesis that suicide 
verdicts are ‘hidden’ within the “Unclassified verdicts” category. 
                                            
13 ‘Narrative verdicts and their impact on mortality statistics in England and Wales’ in Health 
Statistics Quarterly 49, Spring 2011 (ONS) 
14 Samples were taken from each coroner district which had a total number of “Unclassified 
verdicts” greater than or equal to five 
 27

Coroners Statistics 2012 
The second and third categories were chosen as these are recurring themes 
within the “Unclassified verdicts” category for which no relevant short-form 
verdict currently exists. 
The “Error” category was used to capture any verdicts which were incorrectly 
placed in the “Unclassified verdicts” category, while the “Correct” and 
“Unknown” groups captured the remainder; respectively those which could not 
be placed elsewhere and those where the data was missing or incomplete. 
The categorisation of verdicts completed by the independent assessors was 
based on their own individual opinions; it is therefore important to note the 
subjectivity of this analysis. 
Once the data had been analysed by the assessors we collated the data for 
each year and calculated 95 per cent confidence intervals for each category 
(see Tables A2a and A2b). The 95 per cent confidence intervals were based 
on the exact binomial distribution and, therefore, are not symmetric. 
To measure the agreement between the two assessors the Kappa coefficient 
was used.  This coefficient is a measure of inter-rater agreement particularly 
suited for categorical items such as the six groups. It is commonly understood 
that Kappa coefficient values less than zero indicate no agreement, between 
zero and 0.2 as slight agreement, between 0.21 and 0.40 as fair agreement, 
between 0.41 and 0.60 as moderate agreement, between 0.61 and 0.80 as 
substantial agreement, and between 0.81 and 1 as almost perfect 
agreement15. 
Results 
Overall, across the 2,196 verdicts, the results showed an agreement between 
the two assessors using the Kappa Statistic Test (see Table A1), indicated by 
a Kappa coefficient value of 0.61 (95 per cent confidence interval between 
0.59 and 0.63). 
Table A1: Agreement between the two assessors 
Category
Correct
Could 
indicate 
suicide
Error
Indicates 
alcohol 
abuse
Medical or surgical 
intervention 
unsuccessful
Unknown
Correct
2
0
36
0
2
Could indicate suicide
5
96
39
0
1
2
Error
291
12
50
6
117
87
Indicates alcohol abuse
2
2
0
113
0
1
Medical or surgical 
intervention unsuccessful
16
1
0
7
463
10
Unknown
8
0
1
0
3
819
4
 
                                            
15 Landis, J.R.; & Koch, G.G. (1977). "The measurement of observer agreement for 
categorical data". Biometrics 33 (1): 159–174. 
 28

Coroners Statistics 2012 
In 2011, the category containing the highest number of sample verdicts was 
“Unknown” (40 per cent according to Coroner 1, 48 per cent according to 
Coroner 2).  This category has consistently had the highest number of sample 
verdicts since 2007 (see Tables A2a and A2b). 
The percentage of verdicts in “Could indicate suicide” in 2011 was between 
five per cent (Coroner 1) and six per cent (Coroner 2).  This percentage has 
been fairly stable since 2007, fluctuating between five and eight per cent of 
the total.  The percentage is relatively low, which corresponds with the 
findings from the ONS study on narrative verdicts. 
Between 2007 and 2009 the number of verdicts in the “Indicates alcohol 
abuse” category decreased, however since 2009 this number has been 
increasing. 
The “Medical or surgical intervention unsuccessful” category represented 
between 22 per cent of sample verdicts in 2011 (Coroner 1) and 23 per cent 
(Coroner 2).  The number in this category has fluctuated since 2007, although 
there was an increase of between three (Coroner 2) and five (Coroner 1) 
percentage points from 2010 to 2011. 
Figure A2: Classification of “Unclassified verdicts” returned at inquests, 
England and Wales, 2007-2011 
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Correct 
Unknown 
Medical or
surgical
intervention
unsuccessful
Indicates
alcohol abuse
Could
indicate
suicide
Error 
Percentage of total
Coroner 1
Coroner 2
 
There was a large difference between the number of verdicts classified as 
“Error” by the two assessors.  Coroner 1 recorded 25 per cent of verdicts in 
this category in 2011, compared to only seven per cent recorded by Coroner 
2.  This highlights the subjective nature of the analysis. 
The analysis performed by Coroner 1 showed 66 per cent of verdicts within 
the “Error” category were classed as ‘Accident/ Misadventure’, looking at the 
period 2007 – 2011 as a whole (see Table A4a).  The next most common 
 29

Coroners Statistics 2012 
 30
error was ‘Natural Causes’, which accounted for 16 per cent of error verdicts 
across the period. 
The analysis completed by Coroner 2 placed 31 per cent of “Error” verdicts 
within the ‘Suicide’ category, followed by 17 per cent allocated to 
‘Accident/Misadventure’ (see Table A4b).

Table A2a: Classification of “Unclassified verdicts” sample by Coroner 1, with 95 per cent confidence intervals, 2007-2011 
Mean
C.I.
Mean
C.I.
Mean
C.I.
Mean
C.I.
Mean
C.I.
Correct
2%
(1% - 4%)
2%
(1% - 4%)
3%
(1% - 4%)
2%
(1% - 4%)
1%
(0% - 3%)
Could indicate suicide
5%
(3% - 7%)
7%
(5% - 10%)
8%
(6% - 11%)
6%
(4% - 9%)
6%
(4% - 9%)
Error
25% (21% - 30%)
28% (23% - 32%)
23% (19% - 27%)
25% (21% - 29%)
27% (23% - 32%)
Indicates alcohol abuse
6%
(4% - 8%)
4%
(3% - 7%)
3%
(2% - 6%)
6%
(4% - 8%)
8%
(5% - 11%)
Medical or surgical intervention unsuccessful
22% (18% - 26%)
17% (14% - 21%)
23% (19% - 27%)
28% (24% - 33%)
24% (20% - 28%)
Unknown
40% (35% - 45%)
42% (37% - 46%)
40% (36% - 45%)
33% (29% - 38%)
34% (30% - 39%)
n
444
438
440
435
439
2010
2009
Unclassified verdicts
2011
2008
2007
 
Table A2b: Classification of “Unclassified verdicts” sample by Coroner 2, with 95 per cent confidence intervals, 2007-2011 
Mean
C.I.
Mean
C.I.
Mean
C.I.
Mean
C.I.
Mean
C.I.
Correct
12%
(9% - 15%)
21% (17% - 25%)
12%
(9% - 16%)
14% (11% - 18%)
15% (11% - 18%)
Could indicate suicide
6%
(4% - 8%)
5%
(4% - 8%)
5%
(3% - 7%)
5%
(3% - 7%)
5%
(3% - 7%)
Error
7%
(4% - 9%)
6%
(4% - 9%)
5%
(3% - 7%)
6%
(4% - 9%)
5%
(3% - 7%)
Indicates alcohol abuse
6%
(4% - 8%)
5%
(3% - 7%)
4%
(2% - 6%)
6%
(4% - 8%)
9%
(6% - 12%)
Medical or surgical intervention unsuccessful
23% (19% - 27%)
20% (17% - 24%)
28% (24% - 33%)
33% (28% - 37%)
30% (26% - 34%)
Unknown
48% (43% - 53%)
42% (37% - 47%)
45% (41% - 50%)
37% (32% - 42%)
38% (33% - 43%)
n
444
438
440
435
439
2010
2009
Unclassified verdicts
2011
2008
2007
 
31 

Coroners Statistics 2012 
Table A3: Overall average for each category over the period 2007-2011 
Category
Average for 
Coroner 1
Average for 
Coroner 2
Overall average
Correct
2%
15%
8%
Could indicate suicide
7%
5%
6%
Error
26%
6%
16%
Indicates alcohol abuse
5%
6%
6%
Medical or surgical intervention unsuccessful
23%
27%
25%
Unknown
38%
42%
40%
Notes
The average for "Medical or surgical intervention unsuccessful" for Coroner 1, for example, is 
calculated by averaging the five percentages recorded in this category for the years 2007 - 
2011 (see Table A2a).
The Overall average in the third column of this table is calculated by averaging the averages for 
Coroner 1 and Coroner 2
 
 32 

Coroners Statistics 2012 
 33 
Number Percentage
Number
Percentage
Number
Percentage
Number
Percentage
Number
Percentage
Number
Percentage
Death aggravated by neglect or self neglect
1
1%
0
0%
0
0%
1
1%
0
0%
2
0%
Deaths by accident (including misadventure)
71
63%
70
58%
58
57%
83
78%
88
73%
370
66%
Deaths from industrial diseases
11
10%
15
12%
15
15%
10
9%
8
7%
59
10%
Deaths from natural causes
20
18%
25
21%
19
19%
7
7%
20
17%
91
16%
Dependence on drugs
1
1%
0
0%
0
0%
0
0%
0
0%
1
0%
Drug abuse
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
Inquest adjourned
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
Killed lawfully/ unlawfully
2
2%
2
2%
6
6%
3
3%
1
1%
14
2%
Non-dependent abuse of drugs
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
Not classified
1
1%
1
1%
0
0%
1
1%
0
0%
3
1%
Open verdicts
6
5%
8
7%
4
4%
2
2%
3
3%
23
4%
Suicide
0
0%
0
0%
0
0%
0
0%
0
0%
0
0%
Total
113
100%
121
100%
102
100%
107
100%
120
100%
563
100%
Type of error
2011
2010
2009
2008
2007
Totals
 
Number Percentage
Number
Percentage
Number
Percentage
Number
Percentage
Number
Percentage
Number
Percentage
Death aggravated by neglect or self neglect
0
0%
0
0%
0
0%
0
0%
1
5%
1
1%
Deaths by accident (including misadventure)
12
41%
7
25%
1
5%
1
4%
0
0%
21
17%
Deaths from industrial diseases
4
14%
3
11%
7
32%
2
7%
1
5%
17
13%
Deaths from natural causes
4
14%
2
7%
2
9%
1
4%
4
20%
13
10%
Dependence on drugs
0
0%
3
11%
0
0%
1
4%
3
15%
7
6%
Drug abuse
2
7%
0
0%
0
0%
0
0%
0
0%
2
2%
Inquest adjourned
0
0%
0
0%
0
0%
1
4%
1
5%
2
2%
Killed lawfully/ unlawfully
1
3%
1
4%
1
5%
2
7%
0
0%
5
4%
Non-dependent abuse of drugs
2
7%
0
0%
0
0%
5
19%
0
0%
7
6%
Not classified
0
0%
1
4%
0
0%
0
0%
3
15%
4
3%
Open verdicts
2
7%
2
7%
1
5%
3
11%
0
0%
8
6%
Suicide
2
7%
9
32%
10
45%
11
41%
7
35%
39
31%
Total
29
100%
28
100%
22
100%
27
100%
20
100%
126
100%
Type of error
2011
2010
2009
2008
2007
Totals
 
Table A4b: Error breakdown for Coroner 2, 2007-2011 
Table A4a: Error breakdown for Coroner 1, 2007-2011 

Explanatory notes 
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. 
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. 
Quality and consistency of the statistics 
The figures presented in this report are collected via statistical returns 
completed by coroners.  For the calendar year 2012, returns were received 
from all 111 coroner districts.  The process by which coroners provide their 
returns can vary according to the case management system they use.  
Many coroners (90 per cent) 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.  Every effort is made, however, to ensure that the figures 
presented in this publication are accurate and complete. 
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. 
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 
34 

Coroners Statistics 2012 
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. 
Users 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 the Chief Coroner’s Office, 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 2011 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. 
Symbols and conventions 
The following symbols have been used throughout the tables in this bulletin: 
n/a    = Not applicable 
- 
= Nil 
.. 
= Not available 
 35

Coroners Statistics 2012 
* 
= Number or percentage not shown due to being based on small 
numbers of cases 
(R)  
= Revised data 
Maps 
The maps used in this publication are experimental and any feedback would 
be welcomed.  The categories used in each map have been created using 
appropriate bandwidths. 
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: 
webarchive.nationalarchives.gov.uk/20110218135832/http://rds.homeoffice.
gov.uk/rds/hosbarchive.html 
Editions of this bulletin for years up to and including 2009, 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  
 36

Coroners Statistics 2012 
Glossary 
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 
In England and Wales, all violent, unnatural or accidental deaths, deaths of 
unknown cause, deaths that might have been due to an industrial disease or 
related to the deceased’s employment, and all deaths of persons in prison 
or police 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: 
www.legislation.gov.uk/ukpga/1988/13/contents  
The more recent amendments to the Coroners Rules may be found at:  
www.legislation.gov.uk/uksi?title=coroners%20rules 
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 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. 
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. 
Out of England Orders 
Every person wanting to remove a body of a deceased person out of 
England and Wales must give notice of such intention to the coroner within 
whose jurisdiction the body is lying.  This notice allows the coroner to 
consider whether an inquest or post-mortem is necessary before the 
coroner gives permission for the removal of the body. 
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Coroners Statistics 2012 
 
Inquests 
A coroner must hold an inquest if the body of a person (‘the deceased’) lies 
within his or her district 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.   
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Coroners Statistics 2012 
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 
the finders were.  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 2012, 
but a provisional figure has been derived from the monthly registration 
figures which are published by ONS at regular intervals. 
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Coroners Statistics 2012 
 40
Contacts 
Current and previous editions of this publication are available for download 
at www.gov.uk/government/organisations/ministry-of-
justice/series/coroners-and-burials-statistics  
The spreadsheet file of the statistical tables referred to in this bulletin is also 
available for download from this address. 
Press enquiries should be directed to the Ministry of Justice press office: 
Tel: xx-xxxx-xxxx 
Email: xxx@xxx.xx  
Other enquiries about these statistics should be directed to: 
Caroline Nauth-Misir 
Ministry of Justice 
7th Floor (7.20) 
102 Petty France 
London 
SW1H 9AJ 
Tel: xx-xxxx-xxxx 
Email: xxx@xxx.xx 
A copy of the data collection form which was sent to coroners may be 
obtained via the contact details above. 
General enquiries about the statistical work of the Ministry of Justice can be 
e-mailed to: xxx@xxx.xx  
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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Produced by the Ministry of Justice 
Alternative formats are available on request from 
xxx@xxx.xx