Statistics on deaths reported to coroners – England and Wales, 2009
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.

Statistics on deaths reported 
to coroners 
England and Wales, 2009 
Ministry of Justice  
Statistics bulletin  
Published May 2010 

 
 
 
 
 
 
 
 
 
 
 
 
 
Statistics on deaths reported to 
coroners 
England and Wales, 2009 
Ministry of Justice 
Statistics bulletin 
Also available on the Ministry of Justice website at 
www.justice.gov.uk/publications/coronersannual.htm 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                            
Executive summary 
This bulletin presents statistics of coroners’ work during the calendar year 
2009, 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. 
Main points 
  Some 229,900 deaths were reported to coroners in 2009, a fall of 4,900 
(2.1 per cent) from the 2008 figure. (Tables 1,2, and 3) 
  The proportion of all registered deaths reported to coroners remained at 
an estimated1 46 per cent in 2009, the same as in 2008. This 
percentage has been relatively consistent over for the last few years.  
(Table 2) 
  The percentage of cases involving post-mortem examinations, as a 
proportion of all deaths reported to coroners, fell slightly from just above 
46 per cent in 2008 to just below in 2009, continuing the existing 
downward trend. (Table 3) 
  Inquests were opened on 31,000 deaths, representing over 13 per cent 
of all deaths reported to coroners, a little higher than the percentage in 
2008. (Table 3) 
  As in recent years, the most common verdicts returned at inquests were 
death by accident or misadventure (in 29 per cent of cases), and deaths 
from natural causes (28 per cent). (Tables 4 and 6) 
  Verdicts of suicide rose by one per cent in 2009 compared to the 
previous year; there were also rises in the number of verdicts of death by 
accident or misadventure, from natural causes, from industrial diseases, 
and open verdicts.  There was also a large rise in the number of non­
specific verdicts, a category which includes narrative verdicts which are 
a factual record of how and in what circumstances the death occurred; 
often used where the cause of death does not easily fit any of the 
standard verdicts. (Table 6) 
 The estimated2 average time taken to process an inquest in 2009 
(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, the same as in 2008. (Table 7) 
1   Statistics on the number of registered deaths in England and Wales are published by the 
Office for National Statistics. However, the total number of registered deaths in 2009 is not 
yet available and has been estimated for the purposes of this table; see Explanatory Notes 
for more information. 
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 and important note on counting methodology 
This bulletin presents statistics of deaths reported to coroners in England 
and Wales in 2009 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. 
Since 1995, coroners have been asked to report on those deaths notified to 
them which resulted in no further action being taken by them (known as 
“NFA cases”), that is, there was no inquest, no post-mortem, and no 
certificate was issued by them for registration purposes. 
Prior to 1995, however, NFA cases were not reported in the annual 
statistics. It should be noted therefore that in Tables 2 and 3, which show 
figures over a number of years, figures for the total number of deaths 
reported to coroners since 1995 are not directly comparable to those for 
earlier years, as they have been counted on a different basis. 
Because of differences between coroners as to how these NFA cases were 
reported in their figures, since 2005 all coroners have been asked to include 
these cases within the figures for all deaths reported that required neither an 
inquest nor a post-mortem, with separate figures for NFA cases only if the 
sex of the deceased was not known. A consistent time series for deaths 
reported excluding NFA cases is therefore not available. 
2 

 
 
 
 
 
 
Deaths reported (Tables 1, 2 and 3, Figures 1 and 2) 
The number of deaths reported to coroners in 2009 fell by 4,900 (2.1 per 
cent) from the previous year, from 234,800 in 2008 to 229,900 during 2009, 
the lowest annual total since 2004. The proportion of registered deaths in 
the calendar year 2009 that were reported to coroners in 2009 remained at 
an estimated 46 per cent, the same level as in 2008. This percentage has 
been relatively consistent for the last few years.  
Figure 1: Registered deaths, and deaths reported to coroners, England 
and Wales, 1950-2009 
Thousands of deaths 
0 
100 
200 
300 
400 
500 
600 
1950 
1960 
1970 
1980 
1990 
2000 
2009 
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 NFA cases, while those to the left exclude NFA cases (see above). 
Until the last few years, the long-term trend in the number and proportion of 
deaths reported, was upwards. Since the Shipman murders came to light 
about a decade ago, there has been more concern about proper process.  
In the longer term, this rise 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. 
3 

 
       
 
         
 
 
 
 
 
 
 
Figure 2: Deaths reported to coroners as a percentage of registered 
deaths, England and Wales, 1995-2009 
Percentage of registered deaths 
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 
Post-mortem examinations held and inquests opened 
(Tables 1, 2, and 3, Figures 3a and 3b) 
Post-mortem examinations were ordered by coroners in 46 per cent of all 
cases reported to them in 2009, a very slight fall compared to 2008 and 
continues the existing downward trend. 
Figure 3a: Post-mortems as a percentage of deaths reported to 
coroners, England and Wales, 1995-2009 
Percentage of deaths reported 
0 
5 
10 
15 
20 
25 
30 
35 
40 
45 
50 
70 
60 
50 
40 
30 
20 
10 
0 
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. 
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 
The actual number of deaths reported to coroners in 2009 where a post­
mortem was held was 105,400, some 3,000 fewer than in the year before, 
reflecting in part the overall decrease in reported deaths. 
Inquests were opened on 31,000 deaths reported to coroners in 2009, just 
22 fewer than in 2008.  Inquest cases represented more than 13 per cent of 
4 

 
        
 
 
all the deaths reported to coroners in 2009, a slightly higher proportion of 
the total than in the previous year. 
Figure 3b: Inquests as a percentage of deaths reported to coroners, 
England and Wales, 1995-2009 
Percentage of deaths reported 
0 
2 
4 
6 
8 
10 
12 
14 
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 
Post-mortems in inquest cases (Table 3) 
When an inquest is held a post-mortem examination has usually been 
conducted, and in 2009 post-mortems were conducted in 91 per cent of 
such cases. This is a slightly lower proportion than in the previous year, 
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 2009 there were nearly 2,800 inquests without a post­
mortem, nearly six 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 2009, 
there were some 77,100 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 39 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 122,000 cases reported to coroners where there was 
neither an inquest nor a post-mortem. This particular category of case has 
generally been increasing in number in recent years.  In addition, those 
cases where there was neither an inquest nor a post-mortem examination 
have increased, as a proportion of all coroners’ cases, from around 40 per 
cent or just above in the late 1990s, to 53 per cent in 2009. 
5 

 
 
 
 
 
                                            
 
Inquest verdicts returned (Tables 4, 5 and 6, Figures 
4, 5 and 6) 
Verdicts were returned at some 29,800 inquests in 2009, nearly 800 more 
than in 2008. As in previous years the most common verdicts in 2009 were 
death by accident or misadventure (8,700, 29 per cent of all verdicts) and  
deaths from natural causes (8,300, 28 per cent).  Unclassified verdicts, 
which category includes narrative verdicts, represented 13 per cent of the 
total, and verdicts of suicide comprised 11 per cent in 2009. 
There were increases in the numbers of verdicts in many categories over 
the past year, including: 
  A 14 per cent rise in non-specific or unclassified verdicts, up 460 to 
nearly 3,800; 
  a 10 per cent rise in the number of deaths by natural causes (up 725 
to 8,300) 
  a 6 per cent rise in the number of verdicts of death from industrial 
disease, up 150 to 2,600. 
The rise in unclassified verdicts is at least in part due to the increasing use 
of what are known as ‘narrative verdicts’ by some coroners (see the 
paragraph on trends, below). A narrative verdict is where, instead of a 
conventional verdict, at the end of the inquest the coroner records a factual 
record of how and in what circumstances the death occurred.  Recent case 
law may be responsible for the increased number of narrative verdicts in 
recent years, including the House of Lords Middleton3 judgement which 
encouraged their use. 
The number of verdicts of death from accident or misadventure returned in 
2009 fell from 9,200 to 8,700, a drop of 6 per cent.  There was also a fall of 
50 (8 per cent) in verdicts relating to drug-related death. 
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 downward trend in the numbers of 
verdicts of suicide, though there are fluctuations within that trend, including 
a rise in the number of such verdicts in 2008 compared to 2007. 
As a proportion of verdicts delivered by coroners during a calendar year, 
there are five main trends, two rising, and three falling: 
  Verdicts of natural causes have risen from 12 per cent in 1994 to around 
28 per cent in 2009. 
3 R v H.M. Coroner for Western Somersetshire and another ex parte Middleton (2004) 
6 

 
 
 
 
 
 
 
 
 
 
 
 
 
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009 
  Non-specific verdicts (which include narrative verdicts, as explained 
above) formed fewer than one per cent of the total until 2001, but 
accounted for more than one in every eight verdicts in 2009. 
  Verdicts of deaths by accident or misadventure have been declining, 
from 47 per cent of verdicts returned in 1994 to 29 per cent in 2009. 
  Suicide verdicts have been declining slowly over the same period, from 
18 per cent in 1994 to around 11 per cent in 2009. 
  Open verdicts have been falling in percentage terms in the last few 
years, from around 11 per cent in the mid-1990s to less than 8 per cent 
in 2009. 
Figure 4: Verdicts returned at inquests, England and Wales, 1995-2009 
Number of verdicts 
30,000 
25,000 
20,000 
15,000 
10,000 
5,000 
0 
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) 
Gender differences (Table 4, Figures 5 and 6) 
The pattern of verdicts differs between males and females.  Male deaths 
accounted for about 69 per cent of all verdicts returned in 2009; but they 
also included  
  92 per cent of verdicts of death from industrial disease;  
  78 per cent of verdicts of suicide, and 
  84 per cent of verdicts of death from dependence on, or non-
dependent abuse of, drugs. 
For females, the most common verdicts were   
7  

 
 
 
 
 
 
 
 
 
 
 
2009 
  death by accident or misadventure (36 per cent of all female 
verdicts) 
 death from natural causes (36 per cent). 
These proportions were all similar to those in recent years.  Females also 
accounted for a relatively high percentage of unclassified or narrative 
verdicts (39 per cent). 
Figure 5: Verdicts returned at inquests by sex, England and Wales, 
 Accident or 
All other 
misadventure 
All other 
17% 
27%
12% 
 Accident or 
misadventure 
Open verdicts 
33% 
7%
Open verdicts 
8% 
Drug-related 
1% 
Drug-related 
Suicide  
2%  
13% 
Suicide 
8%
Natural causes 
 Industrial 
 Industrial
32%
disease 
disease 
12% 
2% 
Males (total = 20,458)
Females (total = 9,323)
 Natural 
causes 
26%
Figure 6: Number of verdicts returned at inquests, by sex, England and 
Wales, 2009 
Number of verdicts 
0 
1,000 
2,000 
3,000 
4,000 
5,000 
6,000 
Accident or 
Suicide 
Industrial 
Natural 
Drug-related 
Open verdicts 
All other 
misadventure 
disease 
causes 
Males 
Females 
8 

 
 
      
   
Age of deceased in inquests where a verdict was returned (Table 5) 
From 2008, coroners were asked to provide information (in summary form) 
on the ages of persons whose deaths proceeded to inquest and a verdict 
was returned during the year. Nearly 44 per cent of completed inquests in 
2009 were on persons who were 65 years of age or more at death.  Less 
than 10 per cent of inquests concluded were into deaths of persons aged 
under 25. There were only ten cases in 2009 where the age of the 
deceased was either not known or could not be readily provided.  
Inquests with juries, and adjourned inquests (Table 7) 
Nearly all inquests concluded in 2009, as in other years, were held without 
juries. The number of inquests held with juries in 2009 was 470 
(representing under 2 per cent of all inquests), a modest fall of about 20 
compared to 2008. Both the number and proportion of inquests held with 
juries have shown a downward trend in recent years; the proportion of 
inquests held with juries has fallen from 3.6 per cent of inquests concluded 
in 1999 to just under 2 per cent in 2009.. 
Around 920 inquests were adjourned by the coroner under Section 16 of the 
Coroners Act 1988 because criminal proceedings took place, and 
subsequently not resumed. This is comparable with the level generally 
prevailing in recent years. 
Time taken to process an inquest (Table 7) 
The estimated average time taken to process an inquest in 2009 (defined as 
being from the time the death was reported until the conclusion of the 
inquest) was 26 weeks to the nearest whole week, the same as in 2007 and 
2008. 
Figure 6a: Estimated average time taken to process an inquest, 2004­
2009 
Weeks 
30 
25 
20 
15 
10 
5 
0 
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. 
2004 
2005 
2006 
2007 
2008 
2009 
9 

 
 
 
 
 
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 2009, 624 finds were reported and 307 inquests were concluded, from 
which a verdict declaring a find to be Treasure was returned in 289 cases. 
There were also three inquests held into Treasure Trove in 2009, relating to 
finds made before the current Act came into force.  It is likely that a few 
such inquests will continue to be held for some time. 
The number of finds reported has been steadily increasing in recent years; 
this is probably because of the increasing popularity of treasure-hunting as 
a hobby. The dip in reported finds in 2001 is almost certainly due to the 
foot-and-mouth outbreak, which severely restricted access to land during 
the spring of that year. 
An annual report on the operation of the Treasure Act 1996 is published by 
the Department for Culture, Media and Sport. 
Figure 7: Finds reported to coroners and inquests held under the 
Treasure Act, 1997-2009 
Number of finds or inquests 
700 
600 
500 
400 
300 
200 
100 
0 
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 
Number of finds reported 
Number of inquests held 
10 

 
 
 
 
 
 
 
 
 
 
 
 
Map of coroner jurisdictions in England and Wales, shaded according to the 
total number of deaths reported to each coroner in 2009 (see overleaf for key 
to jurisdictions) 
11 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Map of coroner jurisdictions in England and Wales – key to jurisdictions 
0 – Avon 
1 – Bedfordshire and Luton 
2 – Berkshire 
3 – Birmingham and Solihull 
4 – Black Country 
5 – Blackburn, Hyndburn and Ribble Valley 
6 – Blackpool/Fylde 
7 – Boston and Spalding 
8 – Bournemouth, Poole and Eastern Dorset 
9 – Bridgend and Glamorgan Valleys 
10 – Brighton and Hove 
11 – Buckinghamshire 
12 – Cardiff and Vale of Glamorgan 
13 – Carmarthenshire 
14 – Central Hampshire 
15 – Central North Wales 
16 – Central and South East Kent 
17 – Ceredigion 
18 – Cheshire 
19 – City and County of Swansea 
[20 – City of London – not visible] 
21 – Cornwall 
22 – Coventry 
23 – Darlington and South Durham 
24 – Derby and South Derbyshire 
25 – East Lancashire 
26 – East London 
27 – East Riding and Hull 
28 – East Sussex 
29 – Eastern Somerset 
30 – Essex and Thurrock 
31 – Exeter and Greater Devon 
32 – Gateshead and South Tyneside 
33 – Gloucestershire 
34 – Great Yarmouth 
35 – Greater Norfolk 
36 – Gwent 
37 – Hartlepool 
38 – Herefordshire 
39 – Hertfordshire 
40 – Inner North London 
41 – Inner South London 
42 – Inner West London 
43 – Isle of Wight 
44 – Isles of Scilly 
45 – Leicester city and South Leicestershire 
46 – Liverpool 
47 – Manchester North 
48 – Manchester South 
49 – Manchester West 
50 – Manchester city 
51 – Mid Kent and Medway 
52 – Mid and North Shropshire 
53 – Milton Keynes 
54 – Neath and Port Talbot 
55 – Newcastle upon Tyne 
56 – North Derbyshire 
57 – North Durham 
58 – North East Hampshire 
59 – North East Kent 
60 – North East Wales 
61 – North Lincolnshire and Grimsby 
62 – North London 
63 – North Northumberland 
64 – North Tyneside 
65 – North West Kent 
66 – North West Wales 
67 – North Yorkshire Eastern District 
68 – North Yorkshire Western District 
69 – North and East Cambridgeshire 
70 – North and West Cumbria 
71 – Northamptonshire 
72 – Nottinghamshire 
73 – Oxfordshire 
74 – Pembrokeshire 
75 – Peterborough 
76 – Plymouth and South West Devon 
77 – Portsmouth and South East Hampshire 
78 – Powys 
79 – Preston and West Lancashire 
80 – Rutland and North Leicestershire 
81 – Sefton, Knowsley and St Helens 
82 – South London 
83 – South Northumberland 
84 – South Shropshire 
85 – South Yorkshire Eastern District 
86 – South Yorkshire Western District 
87 – South and East Cumbria 
88 – South and West Cambridgeshire 
89 – Southampton and New Forest 
90 – Southend-on-Sea 
91 – Spilsby and Louth 
92 – Staffordshire South 
93 – Stamford 
94 – Stoke-on-Trent and North Staffordshire 
95 – Suffolk 
96 – Sunderland 
97 – Surrey 
98 – Teesside 
99 – Telford and Wrekin 
100 – Torbay and South Devon 
101 – Warwickshire 
102 – West Lincolnshire 
103 – West London 
104 – West Sussex 
105 – West Yorkshire Eastern District 
106 – West Yorkshire Western District 
107 – Western Dorset 
108 – Western Somerset 
109 – Wiltshire and Swindon 
110 – Wirral 
111 – Wolverhampton 
112 – Worcestershire 
113 – York city 
12 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tables 
Table 1.  
Deaths reported to coroners, 2009  
Table 2.  
Registered deaths, deaths reported to coroners, and inquests  
opened, 1950-2009  
Table 3.  
Deaths reported to coroners, post-mortem examinations held  
and inquests opened, 1995-2009  
Table 4.  
Inquest verdicts returned, 2009  
Table 5.  
Age of deceased in inquests where a verdict was returned,  
2009  
Table 6.  
Inquest verdicts returned, 1995-2009  
Table 7.  
Inquests concluded which were held with juries and inquests  
adjourned; High Court orders and exhumations, 1995-2009  
Table 8.  
Treasure inquests, 1995-2009  
Table 9.  
Reported deaths, post-mortems and inquests by jurisdiction,  
2009, and comparison with 2008  
Table 10.  
Inquest verdicts returned, by jurisdiction, 2009  
13  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 1: Deaths reported to coroners, 2009 
England and Wales 
Males 
Number of reported deaths 
Females 
Total 
Total deaths reported to coroners, 2009 (1)(2) 
122,956 
105,853 
229,883 
Inquests 
Deaths reported where an inquest was opened 
Deaths reported where no inquest occurred (1)(2) 
21,167 
101,789 
9,810 
96,043 
30,977 
198,906 
Post-mortem examinations 
Deaths reported where a post-mortem took place 
Deaths reported without a post-mortem (1)(2) 
63,283 
59,673 
42,071 
63,782 
105,354 
124,529 
(1) This row includes deaths referred to the coroner where no certificate of any kind was issued ("no further action" cases). 
(2) The total column includes "no further action" cases which could not be categorized into males and females. 
Table 2: Registered deaths, deaths reported to coroners, and inquests opened, 1950-2009 
England and Wales 
Thousands and percentages 
Deaths reported to coroners 
Inquests opened 
Registered 
Year 
deaths 
(thousands) 
Number 
(thousands) (1) 
As a percentage 
of registered 
deaths 
Number 
(thousands) 
As a percentage of 
deaths reported to 
coroners (1) 
1950 
1960 
1970 
1980 
1990 
510.3 
526.3 
575.2 
581.4 
564.8 
83.6 
101.1 
133.4 
170.2 
180.1 
16.4% 
19.2% 
23.2% 
29.3% 
31.9% 
25.8 
26.3 
24.9 
23.1 
22.1 
30.9% 
26.0% 
18.7% 
13.6% 
12.3% 
1995 
1996 
1997 
1998 
1999 
565.9 
563.0 
558.1 
553.4 
553.5 
208.5 
212.6 
208.6 
211.4 
220.2 
36.8% 
37.8% 
37.4% 
38.2% 
39.8% 
22.7 
22.3 
22.7 
23.6 
24.4 
10.9% 
10.5% 
10.9% 
11.1% 
11.1% 
2000 
2001 
2002 
2003 
2004 
537.9 
532.5 
535.4 
539.2 
514.3 
218.1 
224.3 
225.0 
227.8 
225.5 
40.5% 
42.1% 
42.0% 
42.2% 
43.9% 
24.9 
25.8 
26.4 
27.1 
28.3 
11.4% 
11.5% 
11.7% 
11.9% 
12.5% 
2005 
2006 
2007 
2008 
2009 
513.0 
502.6 
504.1 
509.1 
500.1 (2) 
232.4 
230.0 
234.5 
234.8 
229.9 
45.3% 
45.8% 
46.5% 
46.1% 
46.0% 
29.3 
29.3 
30.8 
31.0 
31.0 
12.6% 
12.8% 
13.2% 
13.2% 
13.5% 
(1) 'NFA' cases are deaths notified to coroners which required neither an inquest nor a post-mortem, and where no 
certificate of any kind was issued.  From 1995 onwards all 'NFA' cases have been included in the number of reported 
deaths.  Prior to that, these cases were excluded. Figures for 1995 onwards are therefore not directly comparable to those 
for previous years. 
(2) Statistics on the number of registered deaths in England and Wales are published by the Office for National Statistics. 
However, the total number of registered deaths in 2009 is not yet available and has been estimated for the purposes of this 
table; see Explanatory Notes for more information. 
14 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
England and Wales 
Numbers and percentages 
Inquest opened 
No inquest opened 
Post-mortems 
Table 3: Deaths reported to coroners, post-mortem examinations held and inquests opened, 1995-2009 
Post-mortem 
examination held 
No post-mortem 
held 
Post-mortem 
examination held 
No post-mortem 
held 
Number 
% of 
inquest 
cases 
Number 
% of 
inquest 
cases 
Number 
% of non-
inquest 
cases (1) 
Number, 
inc. NFA 
% of non-
inquest 
cases (1) 
Total 
deaths 
reported 
inc. NFA 
Total 
inquests 
opened 
% of 
deaths 
reported 
(1) 
Total post-
mortems 
held 
Total non-
inquest 
cases, inc. 
NFA 
% of 
deaths 
reported 
(1) 
Year 
1995 
22,247 
98.1% 
423 
1.9% 
22,670 
10.9% 
104,151 
56.0% 
81,701 
44.0% 
185,852 
126,398 
60.6% 
208,522 
1996 
21,863 
98.0% 
455 
2.0% 
22,318 
10.5% 
104,321 
54.8% 
85,945 
45.2% 
190,266 
126,184 
59.4% 
212,584 
1997 
22,336 
98.4% 
367 
1.6% 
22,703 
10.9% 
100,679 
54.2% 
85,196 
45.8% 
185,875 
123,015 
59.0% 
208,578 
1998 
23,191 
98.4% 
377 
1.6% 
23,568 
11.1% 
101,165 
53.8% 
86,700 
46.2% 
187,865 
124,356 
58.8% 
211,433 
1999 
23,896 
98.0% 
479 
2.0% 
24,375 
11.1% 
100,884 
51.5% 
94,917 
48.5% 
195,801 
124,780 
56.7% 
220,176 
2000 
24,117 
97.0% 
740 
3.0% 
24,857 
11.4% 
100,419 
52.0% 
92,816 
48.0% 
193,235 
124,536 
57.1% 
218,092 
2001 
24,617 
95.4% 
1,176 
4.6% 
25,793 
11.5% 
96,495 
48.6% 
101,998 
51.4% 
198,493 
121,112 
54.0% 
224,286 
2002 
25,363 
96.0% 
1,067 
4.0% 
26,430 
11.7% 
92,321 
46.5% 
106,248 
53.5% 
198,569 
117,684 
52.3% 
224,999 
2003 
25,754 
95.0% 
1,359 
5.0% 
27,113 
11.9% 
93,856 
46.8% 
106,821 
53.2% 
200,677 
119,610 
52.5% 
227,790 
2004 
26,618 
94.1% 
1,656 
5.9% 
28,274 
12.5% 
89,155 
45.2% 
108,082 
54.8% 
197,237 
115,773 
51.3% 
225,511 
2005 
27,537 
94.1% 
1,734 
5.9% 
29,271 
12.6% 
87,083 
42.9% 
116,047 
57.1% 
203,130 
114,620 
49.3% 
232,401 
2006 
27,305 
93.1% 
2,022 
6.9% 
29,327 
12.8% 
82,919 
41.3% 
117,761 
58.7% 
200,680 
110,224 
47.9% 
230,007 
2007 
28,510 
92.4% 
2,331 
7.6% 
30,841 
13.2% 
81,850 
40.2% 
121,767 
59.8% 
203,617 
110,360 
47.1% 
234,458 
2008 
28,518 
92.0% 
2,481 
8.0% 
30,999 
13.2% 
79,842 
39.2% 
123,943 
60.8% 
203,785 
108,360 
46.2% 
234,784 
2009 
28,213 
91.1% 
2,764 
8.9% 
30,977 
13.5% 
77,141 
38.8% 
121,765 
61.2% 
198,906 
105,354 
45.8% 
229,883 
(1) Percentages shown are of deaths reported including "no further action" (NFA) cases.  NFA cases are deaths notified to coroners which required neither an inquest nor a post-mortem, and where no 
certificate of any kind was issued.  From 1995 onwards all 'NFA' cases have been included in the number of reported deaths.  Prior to that, these cases were excluded.  There are therefore no directly 
comparable figures for the total number of reported deaths including 'NFA' cases prior to 1995. 
15 

 
 
                     
                       
                     
                         
                         
                         
                  
                     
                  
                         
                         
                         
 
                       
                       
                       
                     
                       
                     
                     
                       
                     
                         
                         
                         
                  
                     
                  
                  
                  
                  
                         
                         
                         
                  
                  
                  
                  
                     
                  
                         
                         
                         
                  
                  
                  
                
                  
                
 
 
 
 
 
Table 4: Inquest verdicts returned, 2009 
England and Wales 
Number of verdicts returned 
Verdict 
Males 
Females 
Total 
Homicide, of which: 
killed unlawfully 
156 
66 
222 
killed lawfully 
4 
1 
5 
Suicide 
2,596 
734 
3,330 
Attempted or self-induced abortion 
-
-
-
Cause of death aggravated by lack of 
care, or self-neglect 
26 
10 
36 
Dependence on drugs 
260 
56 
316 
Non-dependent abuse of drugs 
216 
34 
250 
Want of attention at birth 
1 
-
1 
Death from industrial diseases 
2,425 
198 
2,623 
Death by accident or misadventure 
5,585 
3,088 
8,673 
Stillborn 
5 
2 
7 
Deaths from natural causes 
5,280 
3,001 
8,281 
Open verdicts 
1,583 
657 
2,240 
Disasters 
-
-
-
All other verdicts 
2,321 
1,476 
3,797 
Total verdicts returned, 2009 
20,458 
9,323 
29,781 
Table 5: Age of deceased in inquests where a verdict was returned, 2009 
England and Wales 
Number and percentage 
Number of 
As a % of total 
Age of deceased at time of death 
inquest verdicts 
verdicts 
returned, 2008 
returned 
Under 1 year 
659 
2.2% 
1 to 14 years 
428 
1.4% 
15 to 24 years 
1,672 
5.6% 
25 to 44 years 
6,469 
21.7% 
45 to 64 years 
7,491 
25.2% 
65 years and over 
13,052 
43.8% 
Age not known or could not be readily provided 
10 
0.0% 
Total verdicts returned, 2009 
29,781 
100.0% 
16 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 6: Inquest verdicts returned, 1995-2009 
England and Wales 
Number of verdicts returned 
Verdict 
1995 
1996 
1997 
1998 
1999 
2000 
2001 
2002 
2003 
2004 
2005 
2006 
2007 
2008 
2009 
Homicide, of which: 
killed unlawfully 
217 
169 
165 
142 
167 
178 
192 
177 
182 
206 
248 
223 
257 
263 
222 
killed lawfully 
6 
1 
2 
3 
2 
4 
2 
6 
1 
5 
4 
2 
2 
2 
5 
Suicide 
3,579 
3,399 
3,355 
3,756 
3,693 
3,626 
3,389 
3,242 
3,255 
3,368 
3,235 
3,220 
3,007 
3,305 
3,330 
Attempted or self-induced
 
abortion
 
Cause of death aggravated by lack 
-
35 
-
59 
-
59 
-
47 
-
44 
-
33 
-
43 
-
46 
-
50 
-
51 
1 
27 
-
30 
-
35 
-
35 
0 
36 
of care, or self-neglect 
Dependence on drugs 
139 
156 
177 
258 
289 
323 
309 
294 
248 
280 
299 
328 
324 
343 
316 
Non-dependent abuse of drugs 
162 
199 
220 
237 
284 
282 
313 
260 
254 
269 
261 
268 
276 
274 
250 
Want of attention
 
at birth
 
9
 5
 4
 5
 1
 4
 6
 1
 4
 3
 2
 3
 -
1
 1
 
Death from industrial diseases 
1,878 
1,784 
1,836 
2,091 
2,373 
2,591 
2,661 
2,653 
2,403 
2,571 
2,567 
2,496 
2,332 
2,474 
2,623 
Death by accident or misadventure 
9,142 
9,286 
9,646 
9,199 
9,558 
9,796 
9,882 
9,379 
9,594 
9,420 
9,498 
9,353 
8,930 
9,230 
8,673 
Stillborn
 
8
 6
 6
 
12
 4
 4
 8
 3
 
10
 
11
 
10
 
12
 
21
 
13
 7
 
Deaths from natural causes 
2,483 
2,498 
2,756 
2,852 
3,306 
3,642 
4,068 
4,334 
4,766 
5,296 
6,175 
6,828 
7,011 
7,556 
8,281 
Open verdicts 
2,257 
2,151 
2,319 
2,571 
2,509 
2,449 
2,519 
2,445 
2,619 
2,600 
2,531 
2,378 
2,242 
2,167 
2,240 
Disasters
 
-
-
-
-
-
-
-
-
-
2
 4
 -
-
-
0
 
All other verdicts 
136 
142 
154 
160 
119 
156 
225 
583 
873 
1,412 
1,952 
2,406 
2,923 
3,333 
3,797 
Total verdicts returned 
20,051 
19,855 
20,699 
21,333 
22,349 
23,088 
23,617 
23,423 
24,259 
25,494 
26,814 
27,547 
27,360 
28,996 
29,781 
17 

 
 
        
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
Table 7: Inquests concluded which were held with juries and inquests adjourned; High Court orders and exhumations, 1995-2009, 
estimated average time taken to process inquests, 2004-2009(1) 
England and Wales 
Number 
Year 
 Inquests 
without juries 
Juries 
Inquests with 
juries 
% with juries 
Verdicts / adjournments
Verdicts 
returned 
Inquests 
adjourned and 
not resumed 
% adjourned 
Inquests held 
by order of 
the High 
Court (2) 
Total inquests 
concluded 
Estimated 
average time 
to process an 
inquest 
(weeks)(1) 
Inquisitions 
quashed or 
amended by 
the High 
Court 
Exhumations 
ordered by 
the coroner 
1995 
20,093 
857 
4.1% 
20,051 
899 
4.3% 
20,950 
n/a 
50 
2 
4 
1996
 19,844
 
903
 
4.4%
 
19,855
 
892
 
4.3%
 
20,747
 
n/a
 7
 1
 3
 
1997
 20,774
 
774
 
3.6%
 
20,699
 
849
 
3.9%
 
21,548
 
n/a
 3
 2
 1
 
1998
 21,141
 
1,035
 
4.7%
 
21,333
 
843
 
3.8%
 
22,176
 
n/a
 2
 0
 5
 
1999 
22,298 
823 
3.6% 
22,349 
772 
3.3% 
23,121 
n/a 
-
2 
2 
2000
 23,243
 
824
 
3.4%
 
23,088
 
979
 
4.1%
 
24,067
 
n/a
 1
 1
 7
 
2001
 23,757
 
759
 
3.1%
 
23,617
 
899
 
3.7%
 
24,516
 
n/a
 3
 2
 5
 
2002
 23,859
 
687
 
2.8%
 
23,423
 
1,123
 
4.6%
 
24,546
 
n/a
 2
 1
 3
 
2003
 24,531
 
636
 
2.5%
 
24,259
 
908
 
3.6%
 
25,167
 
n/a
 1
 4
 1
 
2004
 25,869
 
568
 
2.1%
 
25,494
 
943
 
3.6%
 
26,437
 
22
 1
 1
 2
 
2005
 27,302
 
520
 
1.9%
 
26,814
 
1,008
 
3.6%
 
27,822
 
23
 3
 1
 3
 
2006
 27,934
 
569
 
2.0%
 
27,547
 
956
 
3.4%
 
28,503
 
24
 2
 2
 2
 
2007
 27,747
 
539
 
1.9%
 
27,360
 
926
 
3.3%
 
28,286
 
26
 1
 1
 4
 
2008 
29,344 
485 
1.6% 
28,996 
833 
2.8% 
29,829 
26 
-
2 
1 
2009
 30,239
 
466
 
1.5%
 
29,781
 
924
 
3.0%
 
30,705
 
26
 1
 1
 2
 
(1) A direct average of the time taken to process an inquest cannot be calculated from the data collected; an estimate has been made instead.  Figures only relate to those inquests where the death occurred in 
England or Wales; figures are not collected on the time taken to process inquests where the death occurred elsewhere.  Please see Explanatory Notes for more information. Figures were collected on a different 
basis prior to 2004, and therefore comparable figures are not available. 
(2) The 1995 figure for inquests held by order of the High Court includes 48 inquests arising from the Marchioness pleasure boat disaster. 
18 

 
 
       
 
 
 
 
 
 
 
 
 
 
Table 8: Treasure inquests, 1995-2009 
England and Wales 
Number 
Treasure Act 1996 
Treasure trove (1)
Year 
  Number of 
finds reported
  Number of 
inquests 
concluded
 Verdicts of 
treasure 
returned 
Inquests held on 
treasure trove 
1995 
1996 
1997 
1998 
1999 
n/a 
n/a 
54 
147 
170 
n/a 
n/a 
25 
53 
90 
n/a 
n/a 
6 
42 
86 
66 
45 
35 
20 
8 
2000 
2001 
2002 
2003 
2004 (R) 
213 
168 
279 
396 
412 
236 
63 
144 
154 
213 
123 
65 
133 
140 
191 
4 
5 
3 
6 
16 
2005 
2006 
2007 
2008 
2009 
432 
444 
595 
610 
624 
253 
252 
273 
286 
307 
228 
217 
229 
270 
289 
7 
12 
13 
9 
3 
(R) The figure for treasure inquests held by coroners in 2004 has been revised; see 
Explanatory Notes for more information. 
(1)  Relates to finds made before the commencement of the Treasure Act in September 1997 
19 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 9: Reported deaths, post-mortems and inquests by jurisdiction 2009, and comparison with 2008 
County / unitary authority or district 
The Queen's Household 
ENGLAND 
NORTH EAST 
DURHAM 
Darlington and South Durham 
North Durham 
HARTLEPOOL 
NORTHUMBERLAND 
North Northumberland 
South Northumberland 
TEESSIDE 
TYNE AND WEAR 
Gateshead and South Tyneside 
Newcastle upon Tyne 
North Tyneside 
Sunderland 
NORTH WEST 
CHESHIRE 
CUMBRIA 
South and East Cumbria 
North and West Cumbria 
GREATER MANCHESTER 
Manchester city 
Manchester North 
Manchester South 
Manchester West 
LANCASHIRE 
Blackburn, Hyndburn and Ribble Valley 
Blackpool/Fylde 
East Lancashire 
Preston and West Lancashire 
MERSEYSIDE 
Sefton, Knowsley and St Helens 
Liverpool 
Wirral 
2009 cases 
Reported 
deaths 
2009, inc. 
NFA 
Post­
mortems 
2009 
PMs as % 
of rep. 
deaths 
2009 
Inquests 
2009 
0 
0 
n/a 
0 
1,190 
618 
52% 
145 
1,313 
784 
60% 
249 
492 
240 
49% 
50 
730 
334 
46% 
154 
440 
300 
68% 
117 
2,618 
1,024 
39% 
307 
1,945 
823 
42% 
188 
1,849 
736 
40% 
370 
832 
453 
54% 
226 
1,638 
617 
38% 
394 
5,130 
2,444 
48% 
799 
1,022 
642 
63% 
175 
1,267 
655 
52% 
175 
3,136 
1,853 
59% 
783 
2,655 
914 
34% 
469 
3,106 
1,790 
58% 
585 
4,105 
1,922 
47% 
586 
2,689 
1,002 
37% 
363 
1,694 
841 
50% 
130 
636 
420 
66% 
135 
2,760 
1,545 
56% 
409 
2,406 
828 
34% 
270 
2,733 
873 
32% 
507 
1,737 
665 
38% 
267 
Inquests 
as % of 
rep. 
deaths 
2009 
n/a 
12% 
19% 
10% 
21% 
27% 
12% 
10% 
20% 
27% 
24% 
16% 
17% 
14% 
25% 
18% 
19% 
14% 
13% 
8% 
21% 
15% 
11% 
19% 
15% 
2008 cases 
Reported 
deaths 
2008, inc. 
NFA 
Post­
mortems 
2008 
PMs as % 
of rep. 
deaths 
2008 
Inquests 
2008 
0 
0 
n/a 
0 
1,087 
657 
60% 
140 
1,222 
772 
63% 
223 
472 
176 
37% 
50 
738 
371 
50% 
106 
489 
335 
69% 
94 
2,731 
1,065 
39% 
349 
1,981 
846 
43% 
244 
1,922 
776 
40% 
294 
864 
533 
62% 
221 
1,685 
599 
36% 
339 
4,714 
2,416 
51% 
775 
1,100 
670 
61% 
176 
1,311 
634 
48% 
141 
2,972 
1,744 
59% 
743 
2,584 
993 
38% 
393 
3,215 
1,954 
61% 
612 
4,094 
2,038 
50% 
658 
2,508 
812 
32% 
297 
1,720 
807 
47% 
127 
664 
432 
65% 
147 
2,979 
1,661 
56% 
446 
2,620 
898 
34% 
270 
2,912 
908 
31% 
509 
1,621 
639 
39% 
267 
% change, 2008 to 2009 
Inquests 
as % of 
rep. 
deaths 
2008 
% change 
in reported 
deaths, 
inc. NFA 
change in 
% PMs 
change in 
% 
inquests 
n/a 
n/a 
n/a 
n/a 
13% 
9.5% 
-8.5% 
-0.7% 
18% 
7.4% 
-3.5% 
0.7% 
11% 
4.2% 
11.5% 
-0.4% 
14% 
-1.1% 
-4.5% 
6.7% 
19% 
-10.0% 
-0.3% 
7.4% 
13% 
-4.1% 
0.1% 
-1.1% 
12% 
-1.8% 
-0.4% 
-2.7% 
15% 
-3.8% 
-0.6% 
4.7% 
26% 
-3.7% 
-7.2% 
1.6% 
20% 
-2.8% 
2.1% 
3.9% 
16% 
8.8% 
-3.6% 
-0.9% 
16% 
-7.1% 
1.9% 
1.1% 
11% 
-3.4% 
3.3% 
3.1% 
25% 
5.5% 
0.4% 
0.0% 
15% 
2.7% 
-4.0% 
2.5% 
19% 
-3.4% 
-3.1% 
-0.2% 
16% 
0.3% 
-3.0% 
-1.8% 
12% 
7.2% 
4.9% 
1.7% 
7% 
-1.5% 
2.7% 
0.3% 
22% 
-4.2% 
1.0% 
-0.9% 
15% 
-7.4% 
0.2% 
-0.2% 
10% 
-8.2% 
0.1% 
0.9% 
17% 
-6.1% 
0.8% 
1.1% 
16% 
7.2% 
-1.1% 
-1.1% 
20 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 9: Reported deaths, post-mortems and inquests by jurisdiction 2009, and comparison with 2008 (continued) 
2009 cases 
2008 cases 
% change, 2008 to 2009 
County / unitary authority or district 
Reported 
deaths 
2009, inc. 
NFA 
Post­
mortems 
2009 
PMs as % 
of rep. 
deaths 
2009 
Inquests 
2009 
Inquests 
as % of 
rep. 
deaths 
2009 
Reported 
deaths 
2008, inc. 
NFA 
Post­
mortems 
2008 
PMs as % 
of rep. 
deaths 
2008 
Inquests 
2008 
Inquests 
as % of 
rep. 
deaths 
2008 
% change 
in reported 
deaths, 
inc. NFA 
change in 
% PMs 
change in 
% 
inquests 
YORKSHIRE AND THE HUMBER 
EAST RIDING and HULL 
2,971 
1,133 
38% 
293 
10% 
3,013 
1,112 
37% 
293 
10% 
-1.4% 
1.2% 
0.1% 
NORTH LINCOLNSHIRE and GRIMSBY 
1,477 
455 
31% 
124 
8% 
1,368 
438 
32% 
127 
9% 
8.0% 
-1.2% 
-0.9% 
YORK CITY 
982 
411 
42% 
101 
10% 
1,084 
442 
41% 
105 
10% 
-9.4% 
1.1% 
0.6% 
North Yorkshire Eastern District 
1,139 
661 
58% 
132 
12% 
1,196 
654 
55% 
125 
10% 
-4.8% 
3.4% 
1.1% 
North Yorkshire Western District 
1,078 
368 
34% 
129 
12% 
1,051 
400 
38% 
126 
12% 
2.6% 
-3.9% 
0.0% 
South Yorkshire Eastern District 
2,513 
1,550 
62% 
352 
14% 
2,751 
1,603 
58% 
366 
13% 
-8.7% 
3.4% 
0.7% 
South Yorkshire Western District 
3,120 
1,514 
49% 
453 
15% 
3,244 
1,504 
46% 
479 
15% 
-3.8% 
2.2% 
-0.2% 
West Yorkshire Eastern District 
3,686 
1,658 
45% 
513 
14% 
3,778 
1,809 
48% 
585 
15% 
-2.4% 
-2.9% 
-1.6% 
West Yorkshire Western District 
3,388 
1,749 
52% 
495 
15% 
3,609 
1,779 
49% 
505 
14% 
-6.1% 
2.3% 
0.6% 
EAST MIDLANDS 
DERBYSHIRE 
Derby and South Derbyshire 
2,600 
1,105 
43% 
283 
11% 
2,709 
1,211 
45% 
295 
11% 
-4.0% 
-2.2% 
0.0% 
North Derbyshire 
1,975 
814 
41% 
327 
17% 
2,099 
652 
31% 
308 
15% 
-5.9% 
10.2% 
1.9% 
LEICESTERSHIRE 
Leicester City and South Leicestershire 
3,318 
865 
26% 
413 
12% 
3,426 
1,257 
37% 
668 
19% 
-3.2% 
-10.6% 
-7.1% 
Rutland and North Leicestershire 
866 
451 
52% 
168 
19% 
874 
486 
56% 
170 
19% 
-0.9% 
-3.5% 
-0.1% 
LINCOLNSHIRE 
Boston and Spalding 
1,021 
413 
40% 
64 
6% 
1,012 
400 
40% 
59 
6% 
0.9% 
0.9% 
0.4% 
West Lincolnshire 
1,558 
525 
34% 
136 
9% 
1,652 
546 
33% 
128 
8% 
-5.7% 
0.6% 
1.0% 
Spilsby and Louth 
522 
279 
53% 
58 
11% 
539 
291 
54% 
56 
10% 
-3.2% 
-0.5% 
0.7% 
Stamford 
139 
70 
50% 
20 
14% 
142 
53 
37% 
12 
8% 
-2.1% 
13.0% 
5.9% 
NORTHAMPTONSHIRE 
2,504 
1,069 
43% 
239 
10% 
2,579 
1,085 
42% 
299 
12% 
-2.9% 
0.6% 
-2.0% 
NOTTINGHAMSHIRE 
6,003 
1,577 
26% 
445 
7% 
6,009 
1,575 
26% 
429 
7% 
-0.1% 
0.1% 
0.3% 
WEST MIDLANDS
HEREFORDSHIRE 
786 
371 
47% 
104 
13% 
869 
370 
43% 
84 
10% 
-9.6% 
4.6% 
3.6% 
SHROPSHIRE 
Mid and North Shropshire 
893 
410 
46% 
89 
10% 
923 
474 
51% 
110 
12% 
-3.3% 
-5.4% 
-2.0% 
South Shropshire 
256 
159 
62% 
45 
18% 
287 
169 
59% 
43 
15% 
-10.8% 
3.2% 
2.6% 
STAFFORDSHIRE 
Staffordshire South 
2,268 
862 
38% 
360 
16% 
2,514 
921 
37% 
354 
14% 
-9.8% 
1.4% 
1.8% 
Stoke-on-Trent and North Staffordshire 
3,712 
1,442 
39% 
468 
13% 
3,702 
1,444 
39% 
480 
13% 
0.3% 
-0.2% 
-0.4% 
TELFORD and WREKIN 
775 
377 
49% 
82 
11% 
761 
394 
52% 
80 
11% 
1.8% 
-3.1% 
0.1% 
WARWICKSHIRE 
1,816 
763 
42% 
222 
12% 
1,935 
847 
44% 
241 
12% 
-6.1% 
-1.8% 
-0.2% 
WEST MIDLANDS 
Birmingham and Solihull 
4,488 
1,761 
39% 
1,082 
24% 
4,370 
1,747 
40% 
1,122 
26% 
2.7% 
-0.7% 
-1.6% 
Black Country 
3,166 
972 
31% 
345 
11% 
3,866 
1,227 
32% 
344 
9% 
-18.1% 
-1.0% 
2.0% 
Coventry 
2,030 
579 
29% 
220 
11% 
1,988 
541 
27% 
211 
11% 
2.1% 
1.3% 
0.2% 
Wolverhampton 
1,172 
436 
37% 
205 
17% 
1,273 
551 
43% 
191 
15% 
-7.9% 
-6.1% 
2.5% 
WORCESTERSHIRE 
2,487 
1,120 
45% 
366 
15% 
2,468 
1,027 
42% 
301 
12% 
0.8% 
3.4% 
2.5% 
21 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 9: Reported deaths, post-mortems and inquests by jurisdiction 2009, and comparison with 2008 (continued) 
2009 cases 
2008 cases 
% change, 2008 to 2009 
County / unitary authority or district 
Reported 
deaths 
2009, inc. 
NFA 
Post­
mortems 
2009 
PMs as % 
of rep. 
deaths 
2009 
Inquests 
2009 
Inquests 
as % of 
rep. 
deaths 
2009 
Reported 
deaths 
2008, inc. 
NFA 
Post­
mortems 
2008 
PMs as % 
of rep. 
deaths 
2008 
Inquests 
2008 
Inquests 
as % of 
rep. 
deaths 
2008 
% change 
in reported 
deaths, 
inc. NFA 
change in 
% PMs 
change in 
% 
inquests 
EAST OF ENGLAND 
BEDFORDSHIRE AND LUTON 
2,025 
812 
40% 
212 
10% 
2,066 
810 
39% 
240 
12% 
-2.0% 
0.9% 
-1.1% 
CAMBRIDGESHIRE 
North and East Cambridgeshire 
382 
221 
58% 
57 
15% 
387 
235 
61% 
67 
17% 
-1.3% 
-2.9% 
-2.4% 
South and West Cambridgeshire 
2,022 
709 
35% 
195 
10% 
1,891 
689 
36% 
192 
10% 
6.9% 
-1.4% 
-0.5% 
ESSEX and THURROCK 
4,599 
2,629 
57% 
492 
11% 
4,698 
2,470 
53% 
509 
11% 
-2.1% 
4.6% 
-0.1% 
HERTFORDSHIRE 
3,055 
1,611 
53% 
386 
13% 
3,268 
1,819 
56% 
413 
13% 
-6.5% 
-2.9% 
0.0% 
NORFOLK 
Great Yarmouth 
744 
296 
40% 
64 
9% 
723 
276 
38% 
50 
7% 
2.9% 
1.6% 
1.7% 
Greater Norfolk 
3,357 
1,593 
47% 
436 
13% 
3,141 
1,634 
52% 
413 
13% 
6.9% 
-4.6% 
-0.2% 
PETERBOROUGH 
1,005 
381 
38% 
92 
9% 
1,025 
377 
37% 
107 
10% 
-2.0% 
1.1% 
-1.3% 
SOUTHEND-ON-SEA 
1,515 
674 
44% 
146 
10% 
1,579 
664 
42% 
139 
9% 
-4.1% 
2.4% 
0.8% 
SUFFOLK 
2,647 
1,313 
50% 
286 
11% 
2,796 
1,389 
50% 
262 
9% 
-5.3% 
-0.1% 
1.4% 
LONDON 
City of London 
134 
43 
32% 
19 
14% 
126 
40 
32% 
17 
13% 
6.3% 
0.3% 
0.7% 
East London 
3,770 
1,814 
48% 
416 
11% 
3,940 
1,822 
46% 
376 
10% 
-4.3% 
1.9% 
1.5% 
Inner North London 
3,538 
1,630 
46% 
597 
17% 
3,061 
1,362 
44% 
460 
15% 
15.6% 
1.6% 
1.8% 
Inner South London 
3,253 
1,906 
59% 
513 
16% 
3,524 
2,134 
61% 
576 
16% 
-7.7% 
-2.0% 
-0.6% 
Inner West London 
2,500 
1,182 
47% 
381 
15% 
2,723 
1,307 
48% 
426 
16% 
-8.2% 
-0.7% 
-0.4% 
North London 
3,840 
1,843 
48% 
490 
13% 
3,822 
1,944 
51% 
512 
13% 
0.5% 
-2.9% 
-0.6% 
South London 
3,217 
1,731 
54% 
309 
10% 
3,285 
1,747 
53% 
296 
9% 
-2.1% 
0.6% 
0.6% 
West London 
3,771 
1,553 
41% 
498 
13% 
3,858 
1,655 
43% 
453 
12% 
-2.3% 
-1.7% 
1.5% 
SOUTH EAST 
BERKSHIRE 
2,529 
1,136 
45% 
301 
12% 
2,690 
1,245 
46% 
309 
11% 
-6.0% 
-1.4% 
0.4% 
BRIGHTON AND HOVE 
1,439 
717 
50% 
234 
16% 
1,416 
710 
50% 
237 
17% 
1.6% 
-0.3% 
-0.5% 
BUCKINGHAMSHIRE 
1,417 
703 
50% 
150 
11% 
1,365 
688 
50% 
170 
12% 
3.8% 
-0.8% 
-1.9% 
EAST SUSSEX 
2,318 
1,431 
62% 
322 
14% 
2,410 
1,385 
57% 
326 
14% 
-3.8% 
4.3% 
0.4% 
HAMPSHIRE 
Central Hampshire 
1,204 
580 
48% 
191 
16% 
1,137 
560 
49% 
180 
16% 
5.9% 
-1.1% 
0.0% 
North East Hampshire 
1,117 
608 
54% 
119 
11% 
1,103 
633 
57% 
120 
11% 
1.3% 
-3.0% 
-0.2% 
Portsmouth and South East Hampshire 
2,593 
1,229 
47% 
371 
14% 
2,682 
1,255 
47% 
309 
12% 
-3.3% 
0.6% 
2.8% 
Southampton and New Forest 
2,082 
772 
37% 
203 
10% 
2,279 
854 
37% 
218 
10% 
-8.6% 
-0.4% 
0.2% 
ISLE OF WIGHT 
670 
417 
62% 
75 
11% 
743 
431 
58% 
89 
12% 
-9.8% 
4.2% 
-0.8% 
KENT 
Central and South East Kent 
1,498 
1,003 
67% 
201 
13% 
1,430 
987 
69% 
164 
11% 
4.8% 
-2.1% 
1.9% 
Mid Kent and Medway 
2,429 
1,292 
53% 
248 
10% 
2,465 
1,389 
56% 
246 
10% 
-1.5% 
-3.2% 
0.2% 
North East Kent 
1,938 
1,232 
64% 
221 
11% 
1,898 
1,176 
62% 
196 
10% 
2.1% 
1.6% 
1.1% 
North West Kent 
1,578 
869 
55% 
231 
15% 
1,638 
926 
57% 
188 
11% 
-3.7% 
-1.5% 
3.2% 
MILTON KEYNES 
781 
513 
66% 
130 
17% 
735 
501 
68% 
104 
14% 
6.3% 
-2.5% 
2.5% 
22 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 9: Reported deaths, post-mortems and inquests by jurisdiction 2009, and comparison with 2008 (continued) 
2009 cases 
2008 cases 
% change, 2008 to 2009 
County / unitary authority or district 
Reported 
deaths 
2009, inc. 
NFA 
Post­
mortems 
2009 
PMs as % 
of rep. 
deaths 
2009 
Inquests 
2009 
Inquests 
as % of 
rep. 
deaths 
2009 
Reported 
deaths 
2008, inc. 
NFA 
Post­
mortems 
2008 
PMs as % 
of rep. 
deaths 
2008 
Inquests 
2008 
Inquests 
as % of 
rep. 
deaths 
2008 
% change 
in reported 
deaths, 
inc. NFA 
change in 
% PMs 
change in 
% 
inquests 
OXFORDSHIRE 
2,000 
846 
42% 
290 
15% 
2,080 
848 
41% 
274 
13% 
-3.8% 
1.5% 
1.3% 
SURREY 
4,095 
2,051 
50% 
372 
9% 
4,290 
2,009 
47% 
388 
9% 
-4.5% 
3.3% 
0.0% 
WEST SUSSEX 
3,149 
1,533 
49% 
293 
9% 
3,137 
1,669 
53% 
355 
11% 
0.4% 
-4.5% 
-2.0% 
SOUTH WEST 
AVON 
4,623 
2,257 
49% 
703 
15% 
4,966 
2,388 
48% 
702 
14% 
-6.9% 
0.7% 
1.1% 
CORNWALL 
2,637 
1,674 
63% 
350 
13% 
2,689 
1,659 
62% 
341 
13% 
-1.9% 
1.8% 
0.6% 
DEVON 
Exeter and Greater Devon 
2,893 
931 
32% 
326 
11% 
2,970 
1,199 
40% 
385 
13% 
-2.6% 
-8.2% 
-1.7% 
Plymouth and South West Devon 
2,178 
1,078 
49% 
390 
18% 
2,210 
1,142 
52% 
387 
18% 
-1.4% 
-2.2% 
0.4% 
Torbay and South Devon 
2,071 
762 
37% 
171 
8% 
2,047 
795 
39% 
159 
8% 
1.2% 
-2.0% 
0.5% 
DORSET 
Bournemouth, Poole and Eastern Dorset 
2,269 
788 
35% 
171 
8% 
2,368 
840 
35% 
179 
8% 
-4.2% 
-0.7% 
0.0% 
Western Dorset 
1,005 
452 
45% 
95 
9% 
1,052 
462 
44% 
98 
9% 
-4.5% 
1.1% 
0.1% 
GLOUCESTERSHIRE 
1,986 
1,256 
63% 
390 
20% 
2,124 
1,284 
60% 
429 
20% 
-6.5% 
2.8% 
-0.6% 
ISLES OF SCILLY 
4 
1 
25% 
1 
25% 
2 
2 
* 
0 
* 
* 
* 
* 
SOMERSET 
Eastern Somerset 
1,037 
568 
55% 
145 
14% 
1,046 
582 
56% 
154 
15% 
-0.9% 
-0.9% 
-0.7% 
Western Somerset 
1,333 
569 
43% 
145 
11% 
1,330 
543 
41% 
157 
12% 
0.2% 
1.9% 
-0.9% 
WILTSHIRE and SWINDON 
2,306 
1,136 
49% 
402 
17% 
2,240 
1,119 
50% 
348 
16% 
2.9% 
-0.7% 
1.9% 
WALES 
Bridgend and Glamorgan Valleys 
2,646 
1,163 
44% 
285 
11% 
2,920 
1,320 
45% 
237 
8% 
-9.4% 
-1.3% 
2.7% 
Cardiff and Vale of Glamorgan 
1,665 
840 
50% 
390 
23% 
1,671 
860 
51% 
409 
24% 
-0.4% 
-1.0% 
-1.1% 
Carmarthenshire 
768 
353 
46% 
91 
12% 
822 
374 
45% 
99 
12% 
-6.6% 
0.5% 
-0.2% 
Central North Wales 
1,287 
768 
60% 
226 
18% 
1,476 
818 
55% 
250 
17% 
-12.8% 
4.3% 
0.6% 
Ceredigion 
284 
196 
69% 
34 
12% 
282 
191 
68% 
41 
15% 
0.7% 
1.3% 
-2.6% 
Gwent 
2,510 
947 
38% 
133 
5% 
2,610 
925 
35% 
152 
6% 
-3.8% 
2.3% 
-0.5% 
Neath and Port Talbot 
466 
262 
56% 
79 
17% 
480 
250 
52% 
48 
10% 
-2.9% 
4.1% 
7.0% 
North East Wales 
1,165 
656 
56% 
233 
20% 
1,143 
646 
57% 
230 
20% 
1.9% 
-0.2% 
-0.1% 
North West Wales 
1,162 
511 
44% 
151 
13% 
1,121 
517 
46% 
163 
15% 
3.7% 
-2.1% 
-1.5% 
Pembrokeshire 
606 
259 
43% 
68 
11% 
641 
240 
37% 
78 
12% 
-5.5% 
5.3% 
-0.9% 
Powys 
301 
221 
73% 
70 
23% 
301 
207 
69% 
63 
21% 
0.0% 
4.7% 
2.3% 
City and County of Swansea 
1,638 
591 
36% 
201 
12% 
1,566 
612 
39% 
192 
12% 
4.6% 
-3.0% 
0.0% 
ENGLAND and WALES 
229,883 
105,354 
46% 
30,977 
13% 
234,784 
108,360 
46% 
30,999 
13% 
-2.1% 
-0.3% 
0.3% 
NOTE:  NFA cases are deaths notified to coroners which required neither an inquest nor a post-mortem, and where no certificate of any kind was issued. 
(1) Percentages not shown because of the low volume of caseload. 
23 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 10: Inquest verdicts returned, by jurisdiction, 2009 
County / unitary authority or district 
Homicide, 
killed 
unlawfully 
and killed 
lawfully 
Suicide 
Lack of care 
or self-
neglect 
Dependence 
on drugs 
Verdict category 
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) 
Total, all 
verdicts 
The Queen's Household 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
ENGLAND 
NORTH EAST 
DURHAM 
Darlington and South Durham 
North Durham 
HARTLEPOOL
 
NORTHUMBERLAND 
North Northumberland 
South Northumberland 
TEESSIDE
 
TYNE AND WEAR 
Gateshead and South Tyneside 
Newcastle upon Tyne 
North Tyneside 
Sunderland 
0 
1 
0 
0 
0 
2 
4 
0 
0 
1 
17 
0 
2 
30 
0 
4 
3 
0 
0 
4 
0 
0 
14 
0 
0 
24
 0
 2
 
10 
0 
0 
18 
0 
1 
19 
0 
0 
2 
0 
1 
2 
26 
24 
43 
4 
39 
39 
108 
2
 12
 10
 6
 
1 
12 
15 
45 
0 
4 
45 
31 
0
 40
 
121
 55
 
2 
38 
81 
41 
6 
40 
60 
98 
0 
20 
79 
55 
0 
62 
39 
195 
11 
8 
9 
13 
7
 10
 
6 
36 
0 
2 
31
 7
 
10 
16 
8 
59 
17 
22 
12 
43 
133 
247 
50 
119 
96 
282 
202 
290 
212 
355 
NORTH WEST 
CHESHIRE 
CUMBRIA 
South and East Cumbria 
North and West Cumbria 
GREATER MANCHESTER 
Manchester city 
Manchester North 
Manchester South 
Manchester West 
LANCASHIRE 
Blackburn, Hyndburn and Ribble Valley 
Blackpool/Fylde
 
East Lancashire 
Preston and West Lancashire 
MERSEYSIDE 
Sefton, Knowsley and St Helens 
Liverpool 
Wirral 
0 
0 
2 
2 
0 
3 
0 
1 
0 
1 
1 
0 
3 
0 
77 
0 
1 
11 
0 
1 
19 
0 
3 
39 
0 
5 
60 
0 
5 
49 
2 
0 
74 
0 
12 
32 
1 
0 
15
 0
 4
 
27 
0 
0 
56 
0 
2 
50 
0 
4 
30 
0 
13 
7 
0 
0 
1 
91 
186 
365 
1 
16 
37 
41 
2 
6 
28 
18 
9 
24 
203 
261 
2 
8 
82 
216 
0 
28 
254 
232 
6 
46 
201 
84 
0 
10 
79 
141 
0
 13
 61
 20
 
0 
14 
47 
56 
0 
43 
113 
126 
2 
12 
94 
68 
10 
30 
132 
164 
4 
33 
59 
87 
39 
70 
13 
46 
12 
2 
28 
184 
19 
83 
52 
33 
65 
148 
7 
85 
7 
2 
8 
11 
21 
69 
10 
9 
9 
93 
21 
34 
830 
166 
92 
755 
475 
653 
636 
356 
122 
164 
431 
249 
484 
245 
24 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 10: Inquest verdicts returned, by jurisdiction, 2009 (continued) 
Verdict category 
County / unitary authority or district 
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) 
Total, all 
verdicts 
YORKSHIRE AND THE HUMBER 
EAST RIDING and HULL 
0 
26 
0 
0 
0 
32 
68 
63 
41 
60 
290 
NORTH LINCOLNSHIRE and GRIMSBY 
3 
19 
0 
3 
1 
17 
33 
25 
4 
37 
142 
YORK CITY 
0 
13 
0 
5 
0 
13 
23 
32 
6 
1 
93 
North Yorkshire Eastern District 
0 
22 
0 
0 
0 
6 
54 
21 
8 
2 
113 
North Yorkshire
 
Western District
 
3
 27
 0
 1
 2
 5
 35
 26
 10
 9
 118 
South Yorkshire Eastern District 
1 
26 
0 
1 
3 
75 
62 
46 
11 
46 
271 
South Yorkshire Western District 
1 
51 
1 
0 
0 
87 
108 
123 
12 
73 
456 
West Yorkshire Eastern District 
2 
58 
0 
13 
19 
80 
142 
114 
37 
49 
514 
West Yorkshire
 
Western District
 
6
 70
 0
 7
 19
 38
 
171
 
107
 16
 20
 454 
EAST MIDLANDS
DERBYSHIRE 
Derby and South Derbyshire 
1 
38 
0 
1 
2 
46 
60 
66 
25 
36 
275 
North Derbyshire 
1 
2 
0 
0 
1 
23 
54 
154 
22 
24 
281 
LEICESTERSHIRE 
Leicester City and South Leicestershire 
2 
46 
0 
1 
0 
26 
185 
254 
27 
95 
636 
Rutland and North Leicestershire 
2 
23 
0 
0 
0 
4 
65 
52 
10 
17 
173 
LINCOLNSHIRE 
Boston and Spalding 
0 
9 
0 
1 
1 
3 
28 
9 
5 
3 
59 
West Lincolnshire 
1 
17 
0 
4 
7 
6 
26 
20 
24 
8 
113 
Spilsby and Louth 
2 
11 
0 
0 
1 
4 
22 
7 
16 
2 
65 
Stamford
 
0
 4
 0
 0
 0
 0
 6
 6
 2
 2
 20 
NORTHAMPTONSHIRE 
4 
39 
0 
1 
1 
23 
108 
69 
26 
20 
291 
NOTTINGHAMSHIRE 
4 
50 
0 
0 
0 
67 
152 
70 
38 
12 
393 
WEST MIDLANDS 
HEREFORDSHIRE 
2 
13 
0 
0 
0 
9 
29 
25 
7 
8 
93 
SHROPSHIRE 
Mid and North Shropshire 
2 
15 
0 
0 
0 
9 
32 
8 
4 
13 
83 
South Shropshire 
1 
14 
1 
0 
0 
4 
15 
1 
3 
5 
44 
STAFFORDSHIRE 
Staffordshire South 
3 
63 
0 
4 
2 
61 
148 
70 
12 
10 
373 
Stoke-on-Trent and North Staffordshire 
1 
21 
1 
4 
0 
59 
124 
59 
19 
117 
405 
TELFORD and WREKIN 
0 
12 
0 
0 
0 
7 
27 
14 
4 
14 
78 
WARWICKSHIRE 
8 
35 
1 
1 
8 
17 
78 
44 
9 
7 
208 
WEST MIDLANDS 
Birmingham and Solihull 
3 
17 
3 
0 
0 
31 
141 
273 
28 
466 
962 
Black Country
 
1
 37
 0
 12
 1
 23
 56
 83
 16
 37
 266 
Coventry
 
5
 30
 0
 1
 5
 8
 50
 82
 18
 5
 204 
Wolverhampton 
0 
6 
1 
1 
0 
3 
17 
46 
11 
31 
116 
WORCESTERSHIRE
 
1
 36
 0
 2
 4
 5
 
111
 99
 34
 50
 342 
25 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 10: Inquest verdicts returned, by jurisdiction, 2009 (continued) 
Verdict category 
County / unitary authority or district 
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) 
Total, all 
verdicts 
EAST OF ENGLAND 
BEDFORDSHIRE and LUTON 
5 
37 
0 
5 
0 
23 
63 
48 
5 
7 
193 
CAMBRIDGESHIRE 
North and
 
East Cambridgeshire
 
1
 
16
 0
 0
 1
 2
 
12
 8
 2
 7
 49 
South and West Cambridgeshire 
1 
34 
1 
1 
0 
14 
67 
52 
5 
26 
201 
ESSEX and THURROCK 
2 
59 
0 
1 
0 
73 
90 
87 
35 
10 
357 
HERTFORDSHIRE 
0 
63 
1 
0 
1 
28 
115 
151 
13 
29 
401 
NORFOLK 
Great Yarmouth
 
4
 8
 0
 0
 0
 6
 
27
 
17
 
12
 1
 75 
Greater Norfolk 
0 
45 
0 
0 
0 
44 
133 
121 
4 
111 
458 
PETERBOROUGH
 
0
 8
 0
 0
 0
 4
 
35
 
19
 
10
 7
 83 
SOUTHEND-ON-SEA
 
1
 23
 0
 0
 0
 18
 28
 13
 23
 30
 136 
SUFFOLK
 
2
 43
 0
 0
 0
 20
 67
 40
 36
 60
 268 
LONDON 
City of London
 
0
 5
 0
 0
 1
 2
 6
 3
 0
 3
 20 
East London
 
6
 50
 1
 2
 0
 41
 71
 69
 56
 35
 331 
Inner North London 
22 
68 
1 
23 
27 
33 
123 
160 
92 
35 
584 
Inner South London 
3 
56 
2 
21 
12 
24 
106 
128 
80 
45 
477 
Inner West London 
2 
54 
3 
8 
11 
7 
140 
88 
32 
35 
380 
North London 
7 
21 
0 
2 
3 
27 
121 
141 
84 
78 
484 
South London 
2 
30 
0 
6 
2 
23 
82 
38 
44 
19 
246 
West London 
2 
91 
0 
4 
2 
26 
136 
95 
34 
61 
451 
SOUTH EAST 
BERKSHIRE 
0 
24 
1 
0 
0 
11 
122 
40 
31 
68 
297 
BRIGHTON and HOVE 
2 
28 
6 
17 
0 
7 
97 
24 
22 
15 
218 
BUCKINGHAMSHIRE 
2 
14 
0 
0 
0 
7 
50 
14 
12 
3 
102 
EAST SUSSEX
 
1
 58
 0
 5
 2
 25
 95
 97
 18
 21
 322 
HAMPSHIRE 
Central Hampshire
 
0
 26
 1
 1
 0
 25
 47
 71
 22
 2
 195 
North East
 
Hampshire
 
0
 23
 1
 0
 0
 10
 41
 18
 13
 4
 110 
Portsmouth and South East Hampshire 
0 
55 
0 
4 
0 
56 
113 
154 
9 
30 
421 
Southampton and New Forest 
3 
24 
0 
5 
0 
24 
67 
54 
11 
18 
206 
ISLE OF
 
WIGHT
 
0
 
10
 0
 2
 2
 8
 
29
 9
 
11
 1
 72 
KENT 
Central and South East Kent 
0 
17 
0 
3 
0 
17 
68 
34 
18 
32 
189 
Mid Kent
 
and Medway
 
1
 39
 0
 0
 0
 60
 68
 47
 16
 26
 257 
North East
 
Kent
 
2
 17
 0
 0
 0
 19
 78
 55
 20
 21
 212 
North West
 
Kent
 
5
 29
 0
 0
 0
 30
 68
 73
 24
 1
 230 
MILTON KEYNES
 
0
 
18
 0
 2
 0
 8
 
41
 
36
 8
 5
 118 
26 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 10: Inquest verdicts returned, by jurisdiction, 2009 (continued) 
Verdict category 
County / unitary authority or district 
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) 
Total, all 
verdicts 
OXFORDSHIRE
 
1
 33
 0
 0
 0
 20
 96
 51
 28
 32
 261 
SURREY 
4 
53 
1 
6 
2 
56 
118 
85 
74 
17 
416 
WEST SUSSEX
 
0
 36
 0
 3
 3
 27
 96
 49
 14
 32
 260 
SOUTH WEST 
AVON 
18 
62 
0 
33 
2 
38 
192 
240 
65 
34 
684 
CORNWALL
 
2
 34
 1
 1
 0
 17
 84
 97
 45
 46
 327 
DEVON 
Exeter and Greater Devon 
3 
54 
0 
6 
35 
22 
166 
81 
15 
8 
390 
Plymouth and South West Devon 
4 
28 
2 
6 
5 
63 
97 
195 
23 
56 
479 
Torbay and South Devon 
0 
25 
0 
1 
0 
14 
49 
12 
12 
7 
120 
DORSET 
Bournemouth, Poole and Eastern Dorset 
0 
25 
0 
5 
1 
14 
41 
29 
17 
21 
153 
Western Dorset
 
0
 11
 0
 1
 0
 11
 24
 11
 24
 0
 82 
GLOUCESTERSHIRE 
2 
42 
0 
0 
0 
34 
147 
86 
30 
25 
366 
ISLES OF
 
SCILLY
 
0
 0
 0
 0
 0
 0
 0
 0
 0
 0
 0 
SOMERSET 
Eastern Somerset 
0 
17 
0 
0 
0 
4 
36 
53 
12 
18 
140 
Western Somerset
 
0
 21
 0
 7
 3
 11
 44
 52
 4
 11
 153 
WILTSHIRE AND
 
SWINDON
 
29
 56
 1
 3
 1
 32
 
102
 
116
 13
 37
 390 
WALES 
Bridgend and Glamorgan Valleys 
1 
17 
0 
0 
0 
10 
68 
38 
19 
28 
181 
Cardiff
 
and Vale of Glamorgan
 
2
 6
 0
 8
 0
 
12
 
55
 
120
 
34
 
127
 364 
Carmarthenshire
 
0
 
12
 0
 0
 0
 3
 
40
 
19
 7
 0
 81 
Central North
 
Wales
 
0
 22
 0
 0
 0
 8
 
108
 60
 17
 32
 247 
Ceredigion
 
0
 5
 1
 0
 0
 0
 
20
 9
 3
 0
 38 
Gwent 
2 
39 
0 
0 
0 
4 
93 
12 
13 
5 
168 
Neath
 
and Port Talbot
 
0
 
24
 0
 0
 1
 2
 
19
 
24
 4
 3
 77 
North East
 
Wales
 
2
 20
 0
 0
 0
 18
 91
 51
 18
 26
 226 
North West
 
Wales
 
0
 17
 1
 1
 2
 11
 45
 30
 7
 17
 131 
Pembrokeshire
 
0
 
11
 0
 0
 0
 5
 
31
 
22
 2
 0
 71 
Powys
 
0
 9
 0
 0
 0
 2
 
25
 
20
 4
 2
 62 
City and County of Swansea 
0 
21 
0 
0 
0 
5 
61 
91 
7 
11 
196 
TOTAL ENGLAND and WALES 
227 
3,330 
36 
316 
250 
2,623 
8,673 
8,281 
2,240 
3,805 
29,781 
(1) All other verdicts include those categories from Tables 4 and 6 for which separate columns are not shown in this table.  
NB: A table showing inquest verdicts by district broken down by males and females can be found in the spreadsheet version of the coroners statistics tables.  
27 

 
 
 
 
 
 
Explanatory notes 
1. This is a National Statistics publication produced by the Ministry of 
Justice. National Statistics are produced to high professional standards 
set out in the National Statistics Code of Practice.  They undergo regular 
quality assurance reviews to ensure that they meet customer needs.  
They are produced free from any political interference. 
2. The data analysed in this publication are based on annual returns from 
H.M. Coroners. Coroners are required under the provisions of Section 
28 of the Coroners Act 1988 to furnish to the Secretary of State returns 
in relation to inquests held and deaths inquired into by him (or her) in 
such form and containing such particulars as the Secretary of State may 
direct. Thanks are due to coroners and their staff for their work in 
preparing these returns. 
Symbols and conventions 
The following symbols have been used throughout the tables in this bulletin: 
n/a 
= Not applicable 
- 
= Nil 
 
.. 
= Not available  
(R) 
= Revised data 
Definitions 
The following brief definitions are intended as a guide to the meaning of 
terms in this bulletin concerning coroners and their work; more detailed 
definitions will be found in the Coroners Act 1988 and the Treasure Act 
1996. 
Coroner; deaths reported 
In England and Wales, all violent and unnatural deaths, sudden deaths of 
unknown cause, and all deaths of persons in custody, are reported to 
coroners. Coroners are appointed by local authorities; they must be 
barristers, solicitors or registered medical practitioners and must have at 
least five years’ standing in the relevant profession.  The relevant legislation 
and guidance is contained within the Coroners Act 1988 and the Coroners 
Rules 1984 (as amended). 
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. 
28 

 
 
 
 
 
                                            
 
 
 
Post mortem examinations 
A coroner may request that a post-mortem examination be conducted, 
whether or not an inquest is held, particularly if the cause of death is not 
clear. In many cases a post-mortem examination is conducted in order to 
determine whether or not an inquest is necessary.  Other post-mortem 
examinations are held which are not ordered by the coroner.  Details of 
these are collected by the Office for National Statistics (ONS).  See the 
further information section below for details of how to obtain statistics on this 
and other related topics. 
Inquests 
A coroner must hold an inquest if the body of a person (‘the deceased’) lies 
within his or her district4 and if he or she has reasonable cause to suspect 
that the deceased: 
(a) died a violent or unnatural death; 
(b) died a sudden death the cause of which is unknown; or 
(c) died in prison or in such place or in such circumstances as to require an 
inquest under any other Act. 
The holding of an inquest requires the coroner to determine: 
(a) who the deceased was; 
(b) how, when and where the deceased came by his or her death, and any 
further particulars necessary to enable the death to be registered. 
Verdicts are returned in nearly all coroners’ inquests.  The exceptions are 
those inquests adjourned by the coroner which he or she later decides not 
to resume, and are mainly inquests into deaths by unlawful killing and 
deaths by dangerous driving or careless driving when under the influence of 
alcohol or drugs, in which court proceedings have been instituted.  This 
avoids the need for two tribunals to consider the same evidence.  A 
“narrative verdict” is where the coroner makes a brief and factual statement 
at the conclusion of the inquest but does not return one of the suggested 
short-form verdicts. 
Timeliness of inquests 
For the purpose of determining the timeliness of inquests, the time taken to 
conduct an inquest is deemed to be from the day the death was reported to 
the coroner until either (a) the day the inquest is concluded by the delivery 
of a verdict or (b) the day the coroner certifies that an adjourned inquest will 
not be resumed. 
The average time for an inquest to be conducted is estimated in the 
following way: Coroners are asked in their annual return to state how many 
inquests were concluded within certain time periods.  There are five time 
4 The cause of death does not need to have arisen within the coroner’s district. 
29 

 
 
 
 
 
bands, which are: within one month; 1-3 months; 3-6 months; 6-12 months; 
and over 12 months. All the inquests falling within a time-band are then 
assumed to have been completed at or near the mid-point of the various 
time-bands for the purposes of calculating the average, although inquests 
within the “under one month” band are assumed to have taken 3 weeks for 
this purpose of this estimation, and those inquests taking over a year to 
conclude were deemed to have taken 18 months, although the time-band 
itself is open-ended. Numbers are then aggregated and the average figure 
(in weeks) calculated in the normal way. 
Only deaths occurring within England and Wales are included in the 
calculation.  Statistics are not collected on the time taken for inquests where 
the death occurred outside England and Wales. Deaths occurring abroad 
are often significantly delayed because of the difficulty, for example, of 
obtaining reports from other countries. 
Juries 
Nearly all inquests are held by a coroner sitting alone, without a jury.  A jury 
must be summoned where the death occurred: 
(a) in prison, or in such a place or such circumstances as to require an 
inquest under another Act; 
(b) in police custody, or resulted from an injury caused by a police officer in 
the purported execution of his or her duty; 
(c) where there are certain statutory reporting obligations under the Health 
and Safety Act 1974 or any other Act, and in certain other circumstances, 
especially where there may be a continuing or recurring danger to the 
public. 
Treasure and treasure trove 
In addition to inquiring into certain deaths, coroners also have jurisdiction to 
inquire into any treasure which is found in their districts and to establish who 
were the finders. With the commencement of the Treasure Act 1996 on 24 
September 1997 inquests into finds which previously might have been 
declared treasure trove are supplemented by those now conducted to 
determine whether finds made on or after that date are treasure. 
Registered deaths 
All deaths in England and Wales must be registered with the Registrar of 
Births and Deaths. The term ‘registered deaths’ in this bulletin refers to 
deaths registered within a specific time period (in this case, calendar years). 
Statistics on registered deaths in England and Wales are published by the 
ONS in their series on mortality statistics, and in their publication Health 
Statistics Quarterly. At the time of going to press, figures had been 
published for the number of registered deaths in the first three quarters of 
2009, but not for the full year as a whole.  Provisional statistics on the total 
number of registered deaths in 2009 will not be available until late May 
2010, after publication of this bulletin, and final figures not until July 2010.  
In the interim period, therefore, an estimate of 500,100 was derived by 
30 

 
 
 
 
 
adding the number of registered deaths in the final quarter of 2008 to the 
provisional total for the first three quarters of 2009. 
Revisions to statistics for previous years 
The provisional figure for the number of registered deaths in 2008 in Table 2 
has been replaced by an actual figure. 
Table 8 incorporates a revision to the number of finds reported to coroners 
in 2004 under the Treasure Act 1996. The coroner for the county of Suffolk 
stated that the coroner for Lowestoft (which was in 2004 a separate district) 
had incorrectly reported the number of Treasure Act inquests concluded in 
2004 as 60 instead of four. 
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. 
Further information on deaths occurring annually in England and Wales is 
published by the Office for National Statistics in their Mortality Statistics 
series (DH1, DH2, etc.); these may be downloaded from their website at 
www.statistics.gov.uk. 
Prior to the transfer of responsibility, the Home Office published statistical 
bulletins based on coroners’ annual returns, since 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: 
www.homeoffice.gov.uk/rds/pubsstatistical.html. 
Although care is taken in completing and analysing the returns used to 
compile the figures in this bulletin, the figures are of necessity subject to 
possible inaccuracies inherent in any large-scale collection of this type.  For 
this reason, figures may not be accurate to the final digit.  In the text, 
numbers have been rounded, usually to the nearest 100, although some 
smaller figures may be given exactly.   
Contact points for further information 
Current and previous editions of this publication are available for download 
at www.justice.gov.uk/publications/coronersannual.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 
31 

 
 
 
 
 
 
Other enquiries about these statistics should be directed to: 
Richard Allen 
Ministry of Justice 
7th Floor (7.18) 
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 can be 
obtained via the contact details above. 
An extended version of Table 10, showing inquest verdicts by district broken 
down by males and females, can be found in the spreadsheet file of the 
statistics tables on the Ministry of Justice website via the web address at the 
top of this page. User feedback would be welcome on the continuing 
relevance of the statistics included in this table. 
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. 
32 

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