Coroners Statistics – England and Wales, 2011
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 2011 
England and Wales 
 
Ministry of Justice 
Statistics bulletin 
 
 
 
 
 
 
Published 17 May 2012 
 

 
 
 
 
 
 
Coroners Statistics 2011 
England and Wales 
 
Ministry of Justice 
Statistics bulletin 
 
 
 
 
 
 
 
 
 
Also available on the Ministry of Justice website at 
www.justice.gov.uk/statistics/coroners-and-burials/deaths  

 
                                           
Executive summary 
This bulletin presents statistics of coroners’ work during the calendar year 2011, 
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 222,371 deaths were reported to coroners in 2011, a fall of 8,224 (3.6 per 
cent) from the 2010 figure. (Tables 1,2, and 3) 
 The proportion of all registered deaths reported to coroners was an estimated1 46 
per cent in 2011, one percentage point lower than in 2010, although in recent 
years this proportion has been relatively consistent. (Table 2) 
 The percentage of cases involving post-mortem examinations, as a proportion of 
all deaths reported to coroners, fell slightly from just above 44 per cent in 2010 to 
42 per cent in 2011, continuing the existing downward trend. (Table 3) 
 Inquests were opened on 30,981 deaths, representing nearly 14 per cent of all 
deaths reported to coroners, a slightly higher proportion than in 2010. (Table 3) 
 As in recent years, the most common verdicts returned at inquests were death 
from natural causes (in 29.5 per cent of cases) and death by accident or 
misadventure (26 per cent). (Tables 4 and 6) 
 Verdicts of suicide rose by 7 per cent in 2011 compared to 2010; there were also 
rises in the number of verdicts of death from natural causes. (Table 6) 
 Also rising were 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 returned where the cause of death does not easily fit 
any of the standard verdicts. (Table 6) 
 There were falls in the number of verdicts of death from accident or misadventure, 
and  specific drug-related causes. (Table 6) 
 The estimated2 average time taken to process an inquest in 2011 (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 and 2010. (Table 7) 
 
1   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 2011 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. 
2   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. 
1

 
Introduction 
This bulletin presents statistics of deaths reported to coroners in England and 
Wales in 2011 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  
(web address). 
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. 
2

 
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:  
for annual summary of monthly figures: 
www.ons.gov.uk/ons/rel/vsob2/monthly-figures-on-deaths-registered-by-area-of-
usual-residence--england-and-wales/index.html 
or, for annual series on mortality statistics: 
www.statistics.gov.uk/hub/population/deaths/mortality-rates/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.  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 2011 have been 
calculated using ONS's monthly provisional figures on death registrations, while 
percentages for 2010 and earlier years have been calculated using final annual 
death registration figures for the relevant year. 
3

Deaths reported (Tables 1, 2 and 3, Figures 1 and 2) 
The number of deaths reported to coroners in 2011 fell by 8,224 (3.6 per cent) 
from the previous year, from 230,595 in 2010 to 222,371 during 2011, reflecting 
the fall in the number of deaths registered in England and Wales.  The proportion 
of registered deaths in the calendar year 2011 that were reported to coroners in 
2011 was an estimated 46 per cent, one percentage point lower than in 2010.  
This percentage has shown a shallow upward trend, but with fluctuations, for the 
last few years.  Of these reported deaths, some 1,837 (0.8 per cent) were reports 
of deaths that had occurred outside England and Wales. 
Figure 1: Registered deaths, and deaths reported to coroners, England and 
Wales, 1950-2010 (ten–yearly intervals), and 2011 
Thousands of deaths
0
100
200
300
400
500
600
1950
1960
1970
1980
1990
2000
2010
2011
Deaths reported to coroners
Registered deaths (w hole column)
 
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, these increases 
have become shallower than previously, and 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. 
 4

Figure 2: Deaths reported to coroners as a percentage of registered deaths, 
England and Wales, 1995-2011 
    
Percentage of registered deaths
0
5
10
15
20
25
30
35
40
45
50
1995
1997
1999
2001
2003
2005
2007
2009
2011
 
Post-mortem examinations held and inquests opened 
(Tables 1, 2, and 3, Figures 3a and 3b) 
Post-mortem examinations were ordered by coroners in 42 per cent of all cases 
reported to them in 2011, a fall compared to 2010, and continuing the existing 
downward trend. 
Figure 3a: Post-mortems as a percentage of deaths reported to coroners, 
England and Wales, 1995-2011 
   
Percentage of deaths reported
0
10
20
30
40
50
60
70
1995
1997
1999
2001
2003
2005
2007
2009
2011
 
NOTE: This graph shows the proportion of all deaths referred to coroners where a post-mortem 
examination took place, whether there was an inquest or not. 
The actual number of deaths reported to coroners in 2011 where a post-mortem 
was held was 93,954, some 7,989 fewer than in the year before, reflecting in part 
the overall decrease in reported deaths. 
 5

Inquests were opened on 30,981 deaths reported to coroners in 2011, which was 
193 more than in 2010.  Inquest cases represented nearly 14 per cent of all the 
deaths reported to coroners in 2011, a small increase, and continuing a long-term 
rising trend. 
Figure 3b: Inquests as a percentage of deaths reported to coroners, England 
and Wales, 1995-2011 
       
Percentage of deaths reported
0
2
4
6
8
10
12
14
16
18
20
1995
1997
1999
2001
2003
2005
2007
2009
2011  
Post-mortems in inquest cases (Table 3) 
When an inquest is held a post-mortem examination has usually been conducted, 
and in 2011 post-mortems were conducted in 88 per cent of such cases.  This is a 
lower proportion than in the previous year by a single  percentage point, 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 2011 there were 3,819 inquests without a post-mortem, over three 
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 2011, there 
were some 66,792 non-inquest cases where a post-mortem was held, and the 
percentage of non-inquest cases that required a post-mortem fell to just below 35 
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 124,598 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 45 per cent or just above ten years 
ago, to 56 per cent in 2011. 
 6

 
                                           
Out of England Orders 
Coroners issued 5,008 orders in 2011, compared with 5,173 issued in 2010, the 
decrease exactly reflecting the fall in the overall number of deaths reported.  In 
both years the number of orders issued represented just over two per cent of the 
total number of deaths reported. 
 
Inquest verdicts returned (Tables 4, 5 and 6, Figures 4, 5 
and 6) 
Verdicts were returned at 29,858 inquests in 2011, which was 473 more than in 
2010.  As in previous years the most common verdicts in 2011 were death from 
natural causes (8,818, or 29.5 per cent), and death by accident or misadventure 
(7,775, representing 26 per cent of all verdicts).  Unclassified verdicts, which 
category includes narrative verdicts, represented 15 per cent of the total, and 
verdicts of suicide comprised 12 per cent in 2011. 
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 it 
was also the category to see the largest rise in terms of numbers, up 436 (5 per 
cent) from 8,382 in 2010 to 8,818 in 2011.  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 17 per cent drop in verdicts of deaths from dependence on 
drugs or non-dependent abuse of drugs, from 483 to 403 and a 4 per cent drop in 
the number of verdicts of death by accident or misadventure (down from 8,113 to 
7,775). 
The rise in unclassified verdicts (shown as ‘All other verdicts’ in Tables 4 and 6) 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. 
Recent case law might 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 
 
3 R v H.M. Coroner for Western Somersetshire and another ex parte Middleton (2004) 
7

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 
five main trends, two rising, and three falling: 
 verdicts of death from natural causes have risen steadily from 12 per cent in 
1995 to more than 29 per cent in 2011; 
 unclassified verdicts (which include narrative verdicts, as explained above) 
formed less than one per cent of the total up to and including 2001, but have 
since risen steadily to account for nearly 15 per cent of verdicts in 2011; 
 verdicts of death by accident or misadventure have been declining steadily, 
from 46 per cent of verdicts returned in 1995 to 26 per cent in 2011; 
 suicide verdicts have been declining slowly over the same period, from 18 per 
cent in 1995 to below 12 per cent in 2011; 
 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 2011. 
Figure 4: Verdicts returned at inquests, England and Wales, 1995-2011 
Number of verdicts
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Other verdicts*
Deaths from natural
causes
Deaths from
industrial diseases
Suicide
Deaths by accident
or misadventure
 
*Includes open verdicts, and non-specific verdicts, etc. (see Table 6) 
 8

Differences in verdicts by sex (Table 4, Figures 5 and 6) 
The pattern of verdicts differs between males and females.  Male deaths 
accounted for about 67 per cent of all verdicts returned in 2011; but they also 
included: 
 93 per cent of verdicts of death from industrial disease;  
 79 per cent of verdicts of suicide, and  
 82 per cent of verdicts of death from dependence on, or non-dependent 
abuse of, drugs.   
These proportions are similar to those in recent years. 
For females, common verdicts included: 
 death by accident or misadventure (38 per cent of all female verdicts), and 
 death from natural causes (also 37 per cent). 
Compared with 2010, both proportions have risen by about five percentage points.  
Females also accounted for a relatively high percentage of unclassified or 
narrative verdicts (41 per cent, against 39 per cent in 2010). 
Figure 5: Verdicts returned at inquests by sex, England and Wales, 2011 
Males (total = 20,041)
 Accident or
mis
adventure
24%
 Natural
causes
28%
 Industrial
disease
12%
Suicide
14%
All other
14%
 Open
verdicts
7%
 Drug
related
2%
Females (total = 9,817)
 Accident or
misadventure
30%
 Natural
causes
33%
 Industrial
disease
2%
Suicide
8%
All other
20%
 Open
verdicts
7%
Drug-related
1%
 
 
 
 
 9

Figure 6: Number of verdicts returned at inquests, by sex, England and 
Wales, 2011 
       
Number of verdicts
0
1,000
2,000
3,000
4,000
5,000
6,000
Accident or
misadventure
Suicide
Industrial
disease
Natural
causes
Drug-related
Open verdicts
All other
Males
Females
 
Age of deceased in inquests where a verdict was returned (Table 5) 
From 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.  Over 46 per cent of completed inquests in 2011 were on persons 
who were 65 years of age or more at death.  Less than eight 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 2011, as in other years, were held without juries.  
The number of inquests held with juries in 2011 was 482 (representing just over 
one and a half per cent of all inquests), a rise of 40 compared to 2010.  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.  Nevertheless, the 
proportion of inquests held with juries has fallen from 3.1 per cent of inquests 
concluded in 2001, to just over 1.5 per cent in 2011. 
Some 943 inquests (representing just over 3 per cent of all inquests concluded) 
were adjourned by the coroner under Section 16 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. 
Time taken to process an inquest (Table 7) 
The estimated average time taken to process an inquest in 2011 (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 and 2010.   
 
 10

Figure 6a: Estimated average time taken to process an inquest, 2004-2011 
             
0
5
10
15
20
25
30
35
40
2004 2005 2006 2007 2008 2009 2010 2011
Weeks
 
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 time 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 2011, 794 finds were reported and 362 inquests were concluded, from which a 
verdict declaring a find to be Treasure was returned in 337 cases.  There were 
three inquests held into Treasure Trove in 2011 (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 in recent years.  This is 
probably because of the increasing popularity of treasure-hunting as a hobby.  The 
dip in reported finds in 2001 was 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. 
 11

Figure 7: Finds reported to coroners and inquests held under the Treasure 
Act, 1997-2011 
  
 
 
 
Number of finds or inquests
0
100
200
300
400
500
600
700
800
900
1,000
1997
1999
2001
2003
2005
2007
2009
2011
Number of finds reported
Number of inquests held
 12

 
 
Tables 
Table 1.  
Deaths reported to coroners, 2011 
Table 2. 
Registered deaths, deaths reported to coroners, and inquests opened, 1950-
2011 
Table 3. 
Deaths reported to coroners, post-mortem examinations held and inquests 
opened, 1995-2011 
Table 4. 
Inquest verdicts returned, 2011 
Table 5. 
Age of deceased in inquests where a verdict was returned, 2011 
Table 6. 
Inquest verdicts returned, 1995-2011 
Table 7. 
Inquests concluded which were held with juries and inquests adjourned; High 
Court orders and exhumations, 1995-2011 
Table 8. 
Treasure inquests, 1997-2011 
Table 9. 
Reported deaths, post-mortems and inquests by jurisdiction, 2011, and 
comparison with 2010 
Table 10. 
Inquest verdicts returned, by jurisdiction, 2011 
Map 
Coroner districts in England and Wales as at 31 December, 2011   
 
 
 
 
 
 
13

 
T
able 2. Registere
d deaths, deaths reported
 to coroners, and inquests 
opened, 1950-20
11
Table 1. Deaths r
eported to coroners, 2011
14

 
Tabl
e 3. Deaths reported to
 
coroners, po
st-mor
tem exam
inations
 held a
nd i
nques
ts open
ed, 199
5-201
1
15

T
a
ble 
4. In
q
ues
t
 verdicts
 re
tu
r
ned, 2011

T
ab
le 
5. 
A
g
e of dece
ase
d i
n 
in
que
s
ts 
wh
e
re a verd
ict
 
was 
r
etu
r
ned, 20
11
 
16

 
Table 6. Inquest verdicts returned, 1995-2011
 
 
 
 
17

T
a
ble 7. Inquests concluded which were held with juries and inquests adj
ourn
ed; Hi
gh 
Cour
t orde
rs 
and 
exhuma
ti
o
n
s
, 19
95-201
1
18

 
 
Table 8
. T
rea
sur
e
 inq
ues
ts,
 19
9
7-2011
19

T
able 9. Re
ported deaths, post-mortems and inquests by jurisdiction, 2011, and comparison with 2010
 
20

 
Table 9. (Continued) Reported deaths, post-mortems and inquests by jurisdiction, 2011, and comparison with 2010
21

 
Table 9. (Continued) Reported deaths, post-mortems and inquests by jurisdiction, 2011, and compari son with 20
10
 
22

T
able 9. (continued) Reported deaths, post-mortems and inquests by jurisdiction, 2011, and comparison with 2010
23

 
Table 10: Inquest verdicts returned, by jurisdiction, 2011
Verdict category
Homicide, 
killed 
unlawfully 
and killed 
lawfully
Suicide
Lack of care 
or self-
neglect
Dependence 
on drugs
Non-
dependent 
abuse of 
drugs
Death from 
industrial 
diseases
Death by 
accident or 
mis-
adventure
Deaths from 
natural 
causes
Open 
verdicts
All other 
verdicts (1)
The Queen's Household
0
0
0
0
0
0
0
0
0
0
0
ENGLAND
NORTH EAST
DURHAM
Darlington and South Durham
1
15
0
0
0
19
37
73
11
13
169
North Durham
0
35
0
2
1
36
56
173
24
26
353
HARTLEPOOL
0
11
0
0
2
14
13
4
2
0
46
NORTHUMBERLAND
North Northumberland
1
12
0
0
1
14
12
58
1
24
123
South Northumberland
0
13
0
0
0
8
22
33
7
6
89
TEESSIDE
0
27
2
1
0
59
119
46
26
4
284
TYNE AND WEAR
Gateshead and South Tyneside
3
18
0
0
0
41
116
52
10
21
261
Newcastle upon Tyne
2
22
0
3
5
31
96
100
12
85
356
North Tyneside
1
19
0
0
0
18
66
81
11
9
205
Sunderland
0
17
0
0
0
49
44
218
8
37
373
NORTH WEST
CHESHIRE
6
65
0
2
0
79
161
295
22
94
724
CUMBRIA
South and East Cumbria
1
4
0
0
0
27
39
61
6
48
186
North and West Cumbria
14
26
0
1
1
26
52
57
5
11
193
GREATER MANCHESTER
Manchester city
3
36
1
1
4
30
179
288
39
157
738
Manchester North
2
50
0
1
0
14
55
236
10
108
476
Manchester South
6
31
1
0
0
30
211
240
42
22
583
Manchester West
1
67
0
14
9
43
144
88
78
197
641
LANCASHIRE
Blackburn, Hyndburn and Ribble Valley
1
28
0
1
0
12
53
124
4
89
312
Blackpool/Fylde
1
14
0
6
1
8
69
14
10
3
126
East Lancashire
2
11
0
0
0
8
54
56
7
15
153
Preston and West Lancashire
2
50
0
1
0
15
94
145
35
130
472
MERSEYSIDE
Sefton, Knowsley and St Helens
0
37
2
2
0
18
90
77
24
5
255
Liverpool
6
29
0
10
9
21
149
210
5
86
525
Wirral
0
21
0
0
1
36
34
118
19
30
259
County / unitary authority or district
Total, all 
verdicts
 
24

T
a
ble 10.	In
quest v
erdicts ret
urned, by j
urisdict
ion, 20
11
25

 
T
able 10. (continued) Inquest verdicts returned, by jurisdiction, 2011
Table 10. (continued) Inquest verdicts returned, by jurisdiction, 2011
Table 10. (continued) 
I
nq
u
e
s
t 
ve
rd
i
c
ts 
returned, by j
urisdiction, 2011
Table 10. (continued) Inquest verdicts returned, by jurisdiction, 2011
Table 10. (con
t
i
n
u
e
d
)
 
I
n
qu
est verdict
s
 r
e
t
u
rn
ed
, 
by
 j
uri
sdiction, 2011
 
26

T
a
ble 10. (continued) Inquest verdicts returned, by jurisdiction, 2011
27

 
28 
Map of coroner jurisdictions in England and Wales during 2011 (see below 
for key to jurisdictions) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 
28

 
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 
 
 
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 
 
29

 
Explanatory notes 
The United Kingdom Statistics Authorit
National Statistics, in accordance
Service Act 2007 and signifying compliance with the Code of Practice for 
Official Statistics. 
y has designated these statistics as 
 with the Statistics and Registration 
 
adily accessible; 

he dat
oron
oroners Act 19
c
nquests held an
etary of State may direct.  Thanks 
efinitions
a
rms in t
8
s
 
Designation can be broadly interpreted to mean that the statistics: 
 
meet identified user needs; 
are well explained and re
 
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. 
T
a analysed in this publication are based on annual returns from H.M. 
C
ers.  Coroners are required under the provisions of Section 28 of the 
C
88 to furnish to the Se retary of State returns in relation to 
i
d deaths inquired into by him (or her) in such form and 
containing such particulars as the Secr
are due to coroners and their staff for their work in preparing these returns. 
D
 
The following brief definitions are intended as  guide to the meaning of 
te
his bulletin concerning coroners and their work; more detailed 
definitions will be found in the Coroners Act 19 8 and the Trea ure 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 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:  
http://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. 
30

 
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. 
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. 
 
 
                                            
4 The cause of death does not need to have arisen within the coroner’s district. 
31

 
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. 
 
 
32

 
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 2011, 
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.   
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. 
33

 
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 2010 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. 
Some figures for the number of finds reported in 2007 and 2010 have been 
revised following information which came to light during the data collection 
for the 2011 statistics.  The revised figures are shown in Table 8. 
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://webarchive.nationalarchives.gov.uk/20110218135832/http://rds.home
office.gov.uk/rds/hosbarchive.html 
(this is an archive page; click on the year required) 
34

 
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. 
Contact points for further information 
Current and previous editions of this publication are available for download 
at www.justice.gov.uk/publications/statistics-and-data/coroners-and-
burials/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: xx-xxxx-xxxx 
Email: xxx@xxx.xx  
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: 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. 
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: 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. 
 
 
 
 
 
35

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
© Crown copyright 
Produced by the Ministry of Justice 
Alternative formats are available on request from 
xxx@xxx.xx 
36