Coroners statistics 2014: England and Wales
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.

1

Coroners Statistics 2014
England and Wales

Ministry of Justice
Statistics bulletin

Published 14 May 2015

Coroners Statistics 2014

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Contents
Contents
2
Introduction
3
Executive Summary
9
Deaths reported
10
Post-mortem examinations held and inquests opened
12
Inquests Completed
18
Treasure and Treasure Trove
27
Annex A: Map of coroner areas in England and Wales, 2013
29
Annex B: Further analysis
31
Explanatory notes
33
Contacts
36

Coroners Statistics 2014

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Introduction
This annual bulletin presents statistics of deaths reported to coroners in
England and Wales in 2014. Information is provided on the number of deaths
reported to coroners, post-mortem examinations, inquests opened, and
inquests concluded. Information is provided on the number of deaths reported
to coroners, post-mortem examinations and inquests held, and conclusions
recorded at inquests. The data are collected via statistical returns completed
by coroners. For previous editions of this report please see:
www.gov.uk/government/collections/coroners-and-burials-statistics
This publication should be read alongside the statistical tables which
accompany it, also found via the link above. There is also a supporting CSV
file to allow users to do their own analysis.
In addition to the bulletin and tables we have published a coroners statistical
tool (also available at the link above). The tool provides easier access to local
level data and allows the user to compare up to four areas of interest, for
example it is possible to compare a coroner area with a geographical region,
England or Wales.
The Explanatory Notes section at the end of this bulletin provides information
about statistical revisions, and the symbols and conventions used.
If you have any feedback, questions or requests for further information about
the bulletin, please direct them to the appropriate contact given at the end of
this report.
The legislation
Coroner services in England and Wales are governed by Part 1 of the
Coroners and Justice Act 2009 (the 2009 Act), as well as the rules and
regulations made under it. The 2009 Act came into force in July 2013, largely
replacing the Coroners Act 19881 (the 1988 Act).
The 2009 Act and its rules and regulations can be accessed via the links
below:
www.legislation.gov.uk/ukpga/2009/25/contents
www.legislation.gov.uk/2013?title=coroners

1 The Coroners Act 1988 was repealed in July 2013 with the exceptions of section 13
(application for a fresh coroner investigation or inquest) and 4A(8) (a coroner in Wales being
regarded as a coroner for the whole of Wales).

Coroners Statistics 2014

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Chief Coroner
The 2009 Act created the post of Chief Coroner to provide judicial oversight of
the coroner system and leadership, guidance and support to coroners. The
Chief Coroner’s main statutory responsibilities are to:
 approve all coroner appointments (along with the Lord Chancellor);
 keep a register of coroner investigations lasting more than 12 months;
 collate, monitor and publish coroners’ reports to authorities to prevent
future deaths; and
 give the Lord Chancellor an annual report, which is published and laid
before Parliament (see ‘Chief Coroner’s annual report’ section below).
On 8 April 2015, it was announced that the Lord Chief Justice, after
consultation with the Lord Chancellor, has extended the term of office of His
Honour Judge Peter Thornton QC as Chief Coroner of England and Wales to
1 October 2016.
Further information on the Chief Coroner is available at:
www.judiciary.gov.uk/about-the-judiciary/office-chief-coroner

Coroner areas and structure
Under the 2009 Act, each coroner area has one senior coroner, and one or
more assistant coroners. A coroner area may also have an area coroner (who
may function as a deputy to the senior coroner).
For information on changes to coroner areas, please see Annex B.
Investigations
Under the 2009 Act, a coroner conducts an ‘investigation’ into a death (which
may or may not include an inquest). Much of the coroner’s investigation takes
place before any formal inquest hearing, and includes the coroner considering
whether the duty to hold an inquest applies to an individual case.
A coroner has a duty to investigate a death if:
1) the coroner is made aware that the body is within that coroner’s area, and
2) the coroner has reason to suspect that:
a) the deceased died a violent or unnatural death;
b) the cause of the death is unknown; or
c) the deceased died while in custody or state detention.

The coroner must then establish who has died and how, when, and where
they died.

Coroners Statistics 2014

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A coroner’s inquest is held for all deaths in custody or state detention. An
inquest with a jury is held where the deceased died while in custody or state
detention and the death was violent or unnatural, or of unknown cause; where
the death resulted from an act or omission of a police officer or member of a
service police force in the purported execution of their duties; or where the
death was caused by an accident, poisoning or disease which must be
reported to a government department or inspector. Jury inquests are not
required where the deceased died in custody but from natural causes.
Once the post-mortem examination (including any histology or toxicology) has
concluded, the coroner must decide how to proceed. There are three main
options:
 The post-mortem examination reveals that the deceased died of natural
causes and the coroner thinks that it is not necessary to (investigate or)
continue the investigation. There will be no inquest.
 The post-mortem examination reveals that the deceased died of natural
causes but the coroner considers that it is necessary to (investigate or)
continue the investigation. The coroner must then hold an inquest.
 After the post-mortem examination, the coroner (still) has reason to
suspect that the deceased died a violent or unnatural death, or the cause
of death is unknown, or the deceased died while in custody/state
detention. The coroner must then hold an inquest.
Inquest conclusions
At the end of an inquest, the coroner (or jury if applicable) completes a form
entitled ‘Record of an inquest’. This form documents the ‘conclusion’ of the
coroner or jury as to who died and how, when, and where they died.2
A conclusion consists of the legal ‘determination’, which states who died, and
where, when and how they died; and ‘findings’ which allow the cause of death
to be registered. The coroner or jury may use one of the following short form
conclusions3:
 accident or misadventure
 alcohol/drug related
 industrial disease

2 The 1988 Act term ‘verdict’ was replaced by the 2009 Act term ‘conclusion’.
3 ‘Alcohol/drug related’ and ‘road traffic collision’ are new short form inquest conclusions
under the 2009 Act, which came into effect from 2013. They have been presented for the first
time in this publication.

Coroners Statistics 2014

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 lawful killing
 unlawful killing
 natural causes
 open
 road traffic collision
 stillbirth
 suicide
Suspension of investigation / adjournment of inquest
Under Schedule 1 to the 2009 Act a coroner must suspend an investigation
(and if an inquest has been opened, adjourn that inquest) in the following
circumstances:
 If asked to do so by a prosecuting authority because someone may be
charged with a homicide or related offence involving the death of the
deceased (paragraph 1 of Schedule 1);
 When criminal proceedings have been brought in connection with the
death (paragraph 2 of Schedule 1) ;
 Where there is an inquiry under the Inquiries Act 2005 (paragraph 3 of
Schedule 1);
 If it appears to the coroner that it would be appropriate to do so (paragraph
5 of Schedule 1).
Chief Coroner’s annual report
The Chief Coroner’s annual report to the Lord Chancellor is a statement on
the coroner system for the previous calendar year. It must contain an
assessment of consistency of standards between coroner areas; information
about investigations that have taken over 12 months to complete; and a
summary of reports to prevent future deaths and the responses to these
(previously known as Rule 43 reports). The annual report is published on the
Chief Coroner’s section of the judiciary website. The Chief Coroner’s first
annual report was published in July 20144.
Coroners are therefore now required to notify the Chief Coroner of any
investigation that lasts more than a year and to notify the Chief Coroner of the
date on which any such investigation was subsequently concluded.

4 www.judiciary.gov.uk/related-offices-and-bodies/office-chief-coroner/chief-coroners-annual-
report-2013-14/

Coroners Statistics 2014

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Further information
For further background information on coroners and a flow-chart detailing the
possible outcomes involved when a death is reported to a coroner, please
refer to ‘A Guide to Civil and Administrative Justice Statistics’, which is
available at:
www.gov.uk/government/statistics/guide-to-civil-and-administrative-justice-
statistics
A Glossary providing brief definitions for some of the terms used in this
bulletin can also be found at the link above.
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 conclusion recorded 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:
www.ons.gov.uk/ons/taxonomy/index.html?nscl=Mortality+Rates
For summaries of monthly figures, please see:
www.ons.gov.uk/ons/rel/vsob2/monthly-figures-on-deaths-registered-by-area-
of-usual-residence--england-and-wales/index.html
The Ministry of Justice's coroner statistics differ from ONS figures because
they count two different, albeit related, events. The Ministry of Justice’s
coroner statistics provide the number of deaths which are reported to coroners
in England and Wales. These include deaths reported to coroners which
occurred outside England and Wales. The ONS’ mortality statistics, based on
death registrations, report the number of deaths registered (irrespective of
whether a coroner has investigated) in England and Wales in a particular
year, and therefore do not include deaths that occurred outside England and
Wales.
The proportion of deaths which are reported to coroners has been estimated5
using death registration figures published by ONS. Estimates for 2014 have
been calculated using ONS' monthly provisional figures on death registrations,
while percentages for 2013 and earlier years have been calculated using final
annual death registration figures for the relevant year.

5 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 2014
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.

Coroners Statistics 2014

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This publication includes figures for deaths which occurred in state custody.
Statistics on deaths in prison custody are also published by the National
Offender Management Service (NOMS), accessible via the following link:
www.gov.uk/government/collections/safety-in-custody-statistics
The figures for deaths in custody in this publication relate only to those deaths
which have been reported to a coroner and then reported to MoJ, whereas the
NOMS publication includes all deaths which have occurred in prison custody
and those which occurred whilst the offender was released on temporary
licence for medical reasons.

Coroners Statistics 2014

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Executive Summary
Key Findings
 223,841 deaths were reported to coroners in 2014, a decrease of 4,143
(2%) from 2013, reflecting in part the fall in the number of registered
deaths6 from 2013 to 2014 (down 1%).
 Just under half (45%) of all registered deaths6 were reported to coroners in
2014, the same level as seen in 2013. Over the last ten years this
proportion has been relatively consistent, within the range of 45% to 47%.
 The number of inquests opened in 2014 reduced by 14% to 25,889, which
coincide with the Coroners Act 2009 coming into effect in July 2013. This
means coroners can now conduct a brief investigation prior to deciding
whether an inquest should take place.
 Post-mortem examinations were ordered by coroners in 40% of all cases
reported to them in 2014, down by one percentage point since 2013 and
consistent with the long-term downward trend. Since 1995, the proportion
of post-mortems ordered has decreased by 21 percentage points, from
61% to 40%
 In 2014, the proportion of post-mortems conducted in inquest cases was
76%, down eight percentage points on 2013. Following the implementation
of the Coroners Act 2009 in July 2013, coroners are allowed to hold post-
mortems as part of a brief investigation before deciding if an inquest needs
to be opened which may account for the drop in the figures.
 Despite a fall of 8% in the total number of conclusions recorded (in part
due to the fall in the number of deaths reported to coroners), the number of
suicide conclusions in 2014 has increased by almost 3% from 2013 and
has been steadily rising since 2007.
 Just three of the ten possible inquest conclusion short forms account for
almost 62% of all conclusions recorded (accident and misadventure: 27%,
unclassified: 18% and natural causes: 17%).

Between 2010 and 2013, ‘natural causes’ was the most commonly used
inquest conclusion - however compared with 2013, the number of natural
causes fell by 45% in 2014. This may partly be due to the decrease in the
number of cases reported to coroners, but in addition, may also be due to
the Coroners Act 2009 coming into effect in July 2013. This means that
coroners can now issue a death certificate without holding an inquest
when it is known that a death has occurred naturally.

The estimated average time taken to process an inquest in 2014 (from the
date the death was reported until the conclusion of the inquest, where the
death occurred in England and Wales) was 28 weeks, with a minimum of 3
weeks and maximum 53 weeks across coroner areas.

6 A provisional figure for the number of registered deaths in England and Wales has been used, derived from monthly
figures produced by the Office for National Statistics.

Coroners Statistics 2014
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Deaths reported
The number of deaths reported to coroners in 2014 fell by 4,143 (2%) from the
previous year - from 227,984 in 2013 to 223,841 in 2014 which reflects in part
the decrease in the number of deaths registered in England and Wales (down
1%). The proportion of registered deaths in 2014 that were reported to
coroners was an estimated 45%, no change from 2013 and stabilising the
slight downward trend seen over the last few years.
Figure 1: Registered deaths and deaths reported to coroners, England
and Wales, 2004-2014
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
0
50,000
100,000
150,000
200,000
250,000
300,000
350,000
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Percentage of Registered deaths Reported to the Coroners
Number of Deaths
Year
Registered Deaths Reported to Coroners
Registered Deaths Not Reported to the Coroners
Percentage of Deaths Reported to the Coroners

Over the last decade, the number of registered deaths in England and Wales
has decreased from 512,993 in 2005 to 500,1227 in 2014; however the
number has fluctuated in recent years. The number of deaths reported to
coroners has also fluctuated over the last ten years with 232,401 deaths
reported in 2005, rising to a high of 234,784 in 2008. The figure then fell to
222,371 in 2011, rising briefly to 227,984 in 2013 before falling to 223,841 in
2014.
Map 1 below shows deaths reported in each coroner area in 2014 as a
percentage of the total deaths in each area 8.

7 Provisional figure based on ONS monthly death registration figures for 2014
8 The reported deaths figure for 2014 is provisional, based on ONS monthly death registration figures

Coroners Statistics 2014
11
Map 1: Deaths reported to coroners as a percentage of total deaths in
each area, England and Wales, 20149

The proportion of deaths reported to the coroner varies from 24% in
Hartlepool and North and East Cambridgeshire to 96% in Blackburn,
Hyndburn and Ribble Valley10.

9 Map does not include the Isles of Scilly due to small numbers.
10 The ONS death registration figures are based on area of usual residence whereas the coroners’ figures are based
on the area where a person died. Therefore the coroner office for the City of London may shows a distorted figure of
264% due to the low levels of residence and high level of commuters.

Coroners Statistics 2014
12
Post-mortem examinations held and inquests opened
Post-mortems were held for 89,875 deaths reported to coroners in 2014,
down 4,580 (5%) from 2013.
Post-mortem examinations were ordered by coroners in 40% of all cases
reported to them in 2014, down by one percentage point from 2013, and
consistent with the existing long-term downward trend. Since 1995, the
proportion of post-mortems ordered has decreased by 21 percentage points,
from 61% to 40% (see Table 3).
Inquest cases represented 12% of all the deaths reported to coroners in 2014,
a decrease of 1 percentage point from 2013. Although this difference in
proportion seems small, the actual number of inquests that were opened in
2014 fell 14% to 25,899 compared to 2013. In July 2013, the Coroners Act
2009 came into effect which allowed coroners to conduct a brief investigation
prior to making a decision on whether an inquest should be opened. This
allowed coroners to close cases without having to hold an inquest.
Figure 2: Post-mortems and inquests as a percentage of deaths reported
to coroners, England and Wales, 2004-2014
0%
10%
20%
30%
40%
50%
60%
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Percentage of deaths reported
Post-mortems as a percentage of deaths reported to coroners
Inquests as a percentage of deaths reported to coroners

Coroners Statistics 2014
13
Map 2: Post-mortems held as a proportion of deaths reported to
coroners, England and Wales, 201411

The proportion of post mortems carried out varies from 22% in the Wirral to
62% in North East Kent.

11 Map does not include Isles of Scilly due to small numbers

Coroners Statistics 2014
14
Map 3: Inquests opened as a proportion of deaths reported to coroners,
England and Wales, 201412

The proportion of inquests carried out varies from 5% in Gwent to 22%
in City of London.

12 Map does not include Isles of Scilly due to small numbers

Coroners Statistics 2014
15
Post-mortems in inquest cases
When an inquest is opened, a post-mortem examination has usually been
conducted. In 2014, around three quarters of inquest cases involved a post-
mortem, down eight percentage points on 2013 continuing the declining trend
seen over the past decade (from 94% in 2005). Historically it was quite rare
for an inquest to be opened without a post-mortem; however, since 1997 this
proportion has been gradually increasing, with a sharp increase seen this year
(from 16% to 24% of all inquest cases in 2013 and 2014 respectively) which
may be attributed to the provisions in the Coroners Act 2009 which came into
effect in July 2013, allowing a coroner to conduct a brief investigation
(including a post mortem) prior to making a decision on whether to hold a
formal inquest. These are captured in the potential inquest cases below.
Post-mortems in non-inquest cases
In the majority (87%) of cases referred to coroners, there is no inquest. In
2014 there were 67,108 non-inquest cases where a post-mortem was held.
The percentage of non-inquest cases that required a post-mortem has
remained at 34% for the past three years although this proportion has fallen
steadily prior to this; in 2005 it was 43%.
Post-mortems in potential inquest cases
Prior to July 2013, cases were either categorised as ‘inquest’ or ‘non-inquest’
cases. Changes in the way coroners are able to conduct an investigation
mean that there is now a third category of ‘potential inquest’ cases. This
means that the coroner is investigating the death, but has not yet decided
whether it is necessary to hold an inquest. Depending on whether or not the
coroner deems it necessary to hold an inquest, these cases will all eventually
end up in either the ‘inquest’ or ‘non-inquest’ category.
As of 31 December 2014, there were 3,198 potential inquest cases being
dealt with by coroners in England and Wales with almost all (95%) requiring a
post-mortem.
Cases requiring neither an inquest nor a post-mortem
There were 127,646 cases reported to coroners where there was neither an
inquest nor a post-mortem. This type of case has generally been increasing in
number in recent years (in 2005 there were 116,047 such cases), although
this year has seen a slight decrease from 2013 (down 1,056 or less than 1%).
The proportion of cases where there was neither an inquest nor a post-
mortem examination has increased, as a proportion of all deaths reported to
coroners, from 50% in 2005, to 57% in 2014.

Coroners Statistics 2014
16
Post-mortem rates13, histology14 and toxicology15
Post-mortems can be classed as either standard or non-standard, depending
on the cost of the examination. A non-standard post-mortem is charged at a
higher rate than a standard post-mortem and is defined as a post-mortem
which requires special skills. A non-standard post-mortem could, for example,
require a paediatric or specialist pathologist. In 2014, almost all (95%) of post-
mortems were ordered at a standard rate - this has remained at the same
level since 2011.
In 2014, 18,433 post-mortems included histology; and despite a decrease in
the overall number by 653 from last year, the proportion of post-mortems
which included histology increased by one percentage point to 21% of all post
mortems. In 2014, 13,704 post-mortems held included toxicology (15% of
post-mortems held), which was 419 more than in 2013, an increase of one
percentage point. This follows the slow rising trend seen since 2011.
Out of England Orders
To remove a body of a deceased person out of England and Wales, notice
must be given to the coroner within whose area the body is lying. When the
coroner gives permission for the removal of a body, an Out of England order
is issued.
Coroners issued 5,232 Out of England orders in 2014, compared with 5,051
issued in 2013. In both years the number of orders issued represented 2% of
the total number of deaths reported to coroners which has not changed since
2011 (see Table 5).
Deaths abroad
Of the 223,841 deaths reported to coroners in 2014, some 1,860 (less than
1%) were reports of deaths that had occurred outside England and Wales.
This has remained at the same level since 2011.

13 The fee charged by a pathologist for a standard rate post-mortem is currently £96.80. Non-standard post-mortems
cost £276.90.
14 Histology in the context of post-mortems is the examination of tissues under a microscope.
15 Toxicology in the context of post-mortems is the study of body fluids and tissues for the detection of drugs.

Coroners Statistics 2014
17
Deaths in State Detention
In 2014 a total of 352 deaths were reported to coroners which occurred in
state detention16; 1% of the total number of deaths reported. Deaths in prison
custody and mental health act detention account for 91% of all deaths in state
detention cases (63% and 28% respectively).

Figure 3: Deaths in State Detention by type, England and Wales, 201417
Prison Custody
62.5%
Police Custody
2.8%
Immigration
removal centres
1.1%
Mental Health Act
detention
28.4%
Residents of
Probation
Approved Premises
0.6%
Secure training
centre
0.3%
Release on
temporary licence
(ROTL)
0.3%
Release from
Custody within last
7 days
4.0%

16 This data only represents deaths in custody which were referred to a coroner and subsequently reported to MoJ in
the coroner’s annual return.
17 There were no deaths within “Local authority secure children's homes”

Coroners Statistics 2014
18
Inquests Completed
Conclusions were recorded for 29,15318 inquests in 2014, down by 2,426
(8%) from 2013, reversing the continuing upward trend seen since 1996. The
conclusions recorded in 2014 may relate to cases opened in 2014 or earlier
years. Almost all inquests have a conclusion recorded (98%) and this has
remained at the same level since 2012
Historically the most common conclusions (in order of frequency observed)
were death from natural causes, death by accident or misadventure and
unclassified conclusions. In 2014 the most common conclusions (by order of
frequency) were death by accident and misadventure (7,941 or 27%),
Unclassified (5,261 or 18%) and death by natural causes (4,873 or 17%).
Figure 4: Conclusions recorded at inquest, by category, England and
Wales, 201419
Suicide
13%
Drugs/Alcohol Related
6%
Road Traffic Collision
2%
Industrial Disease
10%
Accident/ Misadventure
27%
Natural Causes
17%
Open
6%
Unclassified
18%
All Other Conclusions
1%

*Killed unlawfully, Killed lawfully, Attempted or self-induced abortion, Cause of death aggravated by lack of care, or
self-neglect, Want of attention at birth, Stillborn, Disasters

18 This includes a small discrepancy with the data received from the West London coroners office, therefore, the sum
of conclusion types may not equal the total number reported.
19 Figures may not equal 100% due to rounding.
*

Coroners Statistics 2014
19
The conclusion of death by natural causes fell by 4,008 or 45% compared to
2013. This may partly be due to the decrease in the number of cases reported
to coroners, but in addition, may also be due to the Coroners Act 2009 coming
into effect in July 2013. This means that coroners can now issue a death
certificate without holding an inquest when it is known that a death has
occurred naturally.
There has been a small drop in the number of unclassified conclusions (82
cases, or 2%), however the proportion of all conclusions recorded as
unclassified increased to 18%, continuing the ongoing steady rise from 1% in
1995. The rise in proportion of unclassified conclusions is partly due to the
increasing use of what are known as ‘narrative conclusions’ by some
coroners. A narrative conclusion is where at the end of the inquest, instead of
a conventional conclusion, the coroner records a factual record of how and in
what circumstances the death occurred. In these cases the conclusion is
recorded as unclassified. As well as narrative conclusions, this category
includes short non-standard conclusions which a coroner or jury might return
when the circumstances do not easily fit any of the standard conclusions20.
Two new short form conclusions have been introduced this year:
drugs/alcohol related and road traffic collision. These conclusions accounted
for 8% of all conclusions recorded (1,645 for Drugs/Alcohol related and 602
for Road Traffic collision).

20 An analysis on unclassified conclusions can be found in the Coroners Statistics 2012 publication (Annex A),
available at: www.gov.uk/government/publications/coroners-statistics

Coroners Statistics 2014
20
Figure 5: Number of conclusions recorded at inquests, England and
Wales, 2004-2014
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Accident/Misadventure
Suicides
Natural Causes
Unclassified
All other conclusions*

*Killed unlawfully, Killed lawfully, Attempted or self-induced abortion, Cause of death aggravated by lack of care, or
self-neglect, Want of attention at birth, Stillborn, Disasters, Open, Industrial Diseases, Drugs/Alcohol Related21, Road
traffic collision and industrial diseases
There are four main trends in the proportion of conclusions recorded by
coroners over the last decade:
 Unclassified conclusions (including narratives, as explained above)
accounted for 7% of all conclusions in 2005, but have since risen steadily
to account for 18% of all conclusions in 2014.
 Conclusions of death by accident or misadventure have been declining
steadily, from 35% of conclusions in 2005 to 26% in 2013; however there
has been a small rise to 27% in 2014.
 Open conclusions have been decreasing over the same period, particularly
over the last few years - they accounted for 6% in 2014 compared with 9%
in 2005; and
 Despite a fall from 12% of all conclusions in 2005 to 11% of all conclusions
in 2007, the proportion of inquests that have been concluded as suicide
have slowly risen to 13% of all conclusions in 2014.

21 for years 2004-2013, this includes the previously used conclusions “dependence on Drugs” and “Non-dependence
on Drugs”
24The fall in natural causes in 2014 may be partly due to the fall in the total number of deaths referred to the coroner
and partly due to the introduction of the two new conclusions “Drugs/Alcohol Related” and “Road Traffic Collision”.
25The rise for “All other conclusions” in 2014 is due to the inclusion of the two new conclusions “Drugs/Alcohol
Related” and “Road Traffic Collision”.
23
24

Coroners Statistics 2014
21
Map 4: Suicide conclusions as a proportion of all inquest conclusions,
England and Wales, 201422

The proportion of conclusions recorded as suicide varies from 4% in
Peterborough to 31% in East Sussex and Ceredigion.

Differences in conclusions recorded by sex
The pattern of conclusions recorded differs between males and females. Male
deaths accounted for around two thirds of all conclusions recorded in 2014,

22 Map does not include Isles of Scilly due to small numbers

Coroners Statistics 2014
22
however they accounted for just over half of deaths reported; this suggests
that males are more likely to die in circumstances that lead to an inquest.
Female deaths accounted for about 34% of all conclusions recorded in 2014
(and 46% of deaths reported).
 Of the 3,851 conclusions of suicide, 78% were for males and 22% for
females.
 Of the 1,882 open conclusions, 70% were for males and 30% for females.
 58% of the 4,873 conclusions of death from natural causes were for males,
the remaining 42% were for females.
Figure 6: Conclusions recorded at inquests by sex, England and Wales,
2014
78%
76%
76%
91%
58%
58%
70%
59%
59%
66%
22%
24%
24%
9%
42%
42%
30%
41%
41%
34%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Suicide
Drugs/Alcohol Related
Road Traffic Collision
Industrial Disease
Accident/Misadventure
Natural Causes
Open
Unclassified
All Other Conclusions*
Total conclusions
Males %
Females %

*Killed unlawfully, Killed lawfully, Attempted or self-induced abortion, Cause of death aggravated by lack of care, or
self-neglect, Want of attention at birth, Stillborn, Disasters

Coroners Statistics 2014
23
Figure 7: Conclusions recorded at inquests by sex, England and Wales,
2014

Suicide
16%
Drugs/Alcohol Related
6%
Road Traffic Collision
2%
Industrial Disease
13%
Accident/Misadventure
24%
Natural Causes
15%
Open
7%
Unclassified
16%
All Other Conclusions*
1%
Males
Suicide
8%
Drugs/Alcohol Related
4%
Road Traffic Collision
1%
Industrial Disease
3%
Accident/Misadventure
34%
Natural Causes
21%
Open
6%
Unclassified
22%
All Other Conclusions*
1%
Females

Coroners Statistics 2014
24
Age of deceased in inquests where a conclusion was recorded
Since 2008, coroners have been asked to provide information (in summary
form) on the ages of persons in inquest cases where a conclusion was
recorded. Of the inquests completed in 2014, half related to persons who
were aged 65 years or over at time of death compared with 7% which related
to persons aged under 25 (see Table 8). Although an age breakdown of
registered deaths in England and Wales in 2014 is not yet available, ONS
figures for 2013 show that 84% of registered deaths in England and Wales
were persons aged 65 or over, with only 1% aged under 25 years old.
Figure 8: Age of deceased in inquests where a conclusion was recorded,
England and Wales, 2014
Under 1 year
1%
1 to 14 years
1%
15 to 24 years
4%
25 to 44 years
19%
45 to 64 years
24%
65 years and over
50%

Inquests with juries and adjourned inquests
The number of inquests held with juries in 2014 was 397 (representing 1% of
all inquests), and a decrease of 59 compared to 2013. Both the number and
proportion of inquests held with juries showed a downward trend until recent
years but the trend appears now to have stabilised, with the proportion
remaining between 1% and 2% for the last eleven years (see Table 10).
In 2014, 698 inquests (representing 2% of all inquests concluded) were
adjourned (and not resumed) by the coroner under Schedule 123 of the

23 Schedule 1 of the Coroners and Justice Act 2009 states that the coroner should adjourn an inquest in the event
that criminal proceedings may or will take place.

Coroners Statistics 2014
25
Coroners and Justice Act 2009 because criminal proceedings took place. This
is the same proportion as 2013 and slightly less than in recent years - around
3% since 2006.
Time taken to process an inquest
The estimated24 average time taken to process an inquest in 2014 (defined as
being from the date the death was reported until the conclusion of the inquest)
was 28 weeks (see Table 10). Only deaths occurring within England and
Wales are included in this estimation.
The maximum average time taken to process an inquest in 2014 was 53
weeks, and the minimum average time was 3 weeks. The large range of
average time (50 weeks – based on 3 and 53 weeks) could be due to the fact
that coroners’ caseloads can vary greatly and a direct comparison is therefore
not advised.
More information about how the average time has been estimated can be
found in the Guide to Civil and Administrative Justice Statistics.

24 A direct average of the time taken to process an inquest cannot be calculated from the summary data collected; an
estimate has been made instead. Please see Guide for more information.

Coroners Statistics 2014
26
Map 5: Average time taken to process inquests, England and Wales,
201425

The average time taken to process an inquest varies from 3 weeks in
Hartlepool to 53 weeks in Inner South London.

25 Map does not include Isles of Scilly due to small numbers

Coroners Statistics 2014
27
Treasure and Treasure Trove
On 24 September 1997, the Treasure Act 1996 came into force and replaced
the common law of Treasure Trove in England and Wales. The 1996 Act
introduced new requirements for reporting and dealing with finds. Not all finds
need be the subject of an inquest. For more information please see:
www.legislation.gov.uk/ukpga/1996/24/contents
In 2014, 778 finds were reported and 347 inquests were concluded. In
addition, there were 14 inquests held into Treasure Trove in 2014 (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 generally increasing over the last ten
years; however, in 2014 there was a slight decrease of 1% compared to 2013.
Of those 347 inquests concluded in 2014, 317 (91%) returned a verdict of
treasure, a slight drop from 93% in 2013.
An annual report on the operation of the Treasure Act 1996 is published by
the Department for Culture, Media and Sport. For more information please
see:
www.gov.uk/government/organisations/department-for-culture-media-
sport/series/treasure-and-portable-antiquities-statistics
Figure 9: Finds reported to coroners, treasure inquests held under the
Treasure Act, and proportion of treasure verdicts returned, 2004-201426
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
100
200
300
400
500
600
700
800
900
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Number of finds reported
Number of inquests concluded
Proportion of Inquests where a treasure verdict was returned

26 This chart does not include reported findings under “Treasure Trove”

Coroners Statistics 2014
28
Map 6: Number of treasure finds reported to coroners, England and
Wales, 201427

The highest number of treasure finds reported to coroner areas were in
Norfolk and Essex, each with 87. Thirty four coroners’ areas had no
treasure finds reported to them.

27 Map does not include Isles of Scilly due to small numbers

Coroners Statistics 2014
29
Annex A: Map of coroner areas in England and Wales,
2013

Key to coroner areas
North East
101 – County Durham and Darlington
103 – Hartlepool
104 – North Northumberland
105 – South Northumberland
106 – Teesside

107 – Gateshead and South Tyneside
108 – Newcastle upon Tyne
109 – North Tyneside
110 – Sunderland

Coroners Statistics 2014
30

North West
201 – Cheshire
203 – South and East Cumbria
204 – North and West Cumbria
205 – Manchester (city)
206 – Manchester North
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 Derbyshire
403 – Leicester and South Leicestershire
404 – North Leicestershire and Rutland
406 – Central Lincolnshire
408 – South Lincolnshire
409 – Northamptonshire
410 – Nottinghamshire

West Midlands
501 – Herefordshire
502 – Shropshire, Telford and Wrekin
504 – Staffordshire South
505 – Stoke-on-Trent and North Staffordshire
507 – Warwickshire
508 – Birmingham and Solihull
509 – Black Country
510 – Coventry
512 – Worcestershire

East of England
601 – Bedfordshire and Luton
602 – North and East Cambridgeshire
603 – South and West Cambridgeshire
604 – Essex
605 – Hertfordshire
607 – Norfolk
609 – Peterborough
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, Torbay and South Devon
906 – Dorset
908 – Gloucestershire
909 – Isles of Scilly
910 – Eastern Somerset
911 – Western Somerset
912 – Wiltshire and Swindon

Wales
1001 – Powys, Bridgend & Glamorgan Valleys
1002 – Cardiff and Vale of Glamorgan
1003 – Carmarthenshire and Pembrokeshire
1004 – North Wales (East and Central)
1005 – Ceredigion
1006 – Gwent
1007 – Swansea and Neath Port Talbot
1009 – North West Wales

31
Annex B: Further analysis on number and proportion
of deaths reported to coroners
The number of deaths reported to coroners in 2014 varied by coroner area –
from 5 in the Isles of Scilly to 6,432 in Essex. There were also over 6,000
deaths reported in the Nottinghamshire coroner area (6,378). The number of
deaths reported in each area will be affected by the size, population and
demographic breakdown of its area so comparisons of deaths reported to
the coroner across coroner areas should be treated with caution,
Figure C1: Number of deaths reported to coroners, 2014
6
10
12
14
19
15
9
4
6
2
2
0
2
4
6
8
10
12
14
16
18
20
<499
500-999
1000-1499 1500-1999 2000-2499 2500-2999 xx-xxxx-xxxx 3500-3999 xx-xxxx-xxxx 4500-4999
>5000
Number of Coroner Areas

However, when looking at the number of deaths reported to coroners in
2014 as a proportion of registered deaths, which should allow for
differences in population characteristics, there is still a wide variation across
coroner areas e.g. 24% in North and East Cambridgeshire compared with
96% in Blackburn, Hyndburn and Ribble Valley.

Coroners Statistics 2014
32
Figure C2: Deaths reported to coroners in 2014 as a proportion of
registered deaths28,29
6
31
37
14
4
2
2
2
0
5
10
15
20
25
30
35
40
<30
31-40
41-50
51-60
61-70
71-80
81-90
91-100
Number of Coroner Areas
Proportion of Deaths Reported to the Coroners

28 Provisional figure based on ONS monthly death registration figures for 2014
29 Data for the City of London has been excluded from this analysis due to the small size of
this coroner area. The total number of coroner areas shown in Figure C2 is therefore 98.

Coroners Statistics 2014
33
Explanatory notes
The United Kingdom Statistics Authority has designated these statistics as
National Statistics, in accordance with the Statistics and Registration
Service Act 2007 and signifying compliance with the Code of Practice for
Official Statistics.
Designation can be broadly interpreted to mean that the statistics:
 meet identified user needs;
 are well explained and readily accessible;
 are produced according to sound methods, and
 are managed impartially and objectively in the public interest.
Once statistics have been designated as National Statistics it is a statutory
requirement that the Code of Practice shall continue to be observed.
The data analysed in this publication are based on annual returns from
coroners. Thanks are due to coroners and their staff for their work in
preparing these returns.
Quality and consistency of the statistics
The figures presented in this report are collected via statistical returns
completed by coroners. For the calendar year 2014, returns were received
nearly all coroner areas electronically (2 were received via post). The
process by which coroners provide their returns can vary according to the
case management system they use. Many coroners (97%) 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. Every effort
is made, however, to ensure that the figures presented in this publication
are accurate and complete.
Returns are individually quality-assured and validated in a process that
highlights inconsistencies between years, and between areas. Checks are
made to ensure that each return is arithmetically correct, e.g subtotals and
overall totals are correctly summed. Unusual or outlying values found within
returns are queried with the data supplier, to confirm whether these are
correct, or that an error exists in the information provided which requires
amendment.
Coroners are independent office-holders, and there is considerable variation
in the way each coroner’s area 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.

Coroners Statistics 2014
34
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, there may
still however 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 areas can be compared on this
basis.
Users of the statistics
The main users of these statistics are coroners themselves, and Ministers
and officials in central government responsible for developing policy with
regard to coroners. Other users include the Chief Coroner’s Office, local
authorities (who are responsible for the appointment and remuneration of
coroners), other central government departments, and those non-
governmental bodies, including various voluntary organisations, with an
interest in coroners and inquests. The statistics are used to monitor the
volume and types of cases dealt with by coroners in England and Wales
each year.
Revisions to statistics for previous years
The estimated figure for the number of registered deaths in 2013 which was
derived for the purposes of Table 2 in last year’s edition of this bulletin has
now been replaced by an actual figure subsequently published by the Office
for National Statistics.
Symbols and conventions
The following symbols have been used throughout the tables in this bulletin:
n/a = Not applicable
-
= Zero
..
= No data available
*
= Number or percentage not shown due to being based on small
numbers of cases
(r)
= Revised data

Coroners Statistics 2014
35
Maps
The maps used in this publication are experimental and any feedback would
be welcomed.
Further notes
Prior to 1 June 2005, policy responsibility for coroners lay with the Home
Office, but on that date it passed to the Department for Constitutional Affairs
as part of machinery of government changes following the 2005 general
election. Responsibility now lies with the Ministry of Justice, which was
created on 9 May 2007.
Prior to the transfer of responsibility, the Home Office published statistical
bulletins based on coroners’ annual returns, from 1980. The last four
bulletins published in the Home Office Statistical Bulletin series were as
follows: for year 2003, bulletin 9/04; for 2002, bulletin 6/03; for 2001, bulletin
3/02; and for year 2000, bulletin 7/01. These may be found at:
webarchive.nationalarchives.gov.uk/20110218135832/http://rds.homeoffice.
gov.uk/rds/hosbarchive.html
Editions of this bulletin for years up to and including 2009, published by the
Ministry of Justice, the Department for Constitutional Affairs, and the Home
Office, were entitled “Statistics on deaths reported to coroners, England and
Wales, (year)”.

Coroners Statistics 2014
36
Contacts
Current and previous editions of this publication are available for download
at:
www.gov.uk/government/collections/coroners-and-burials-statistics
The spreadsheet file of the statistical tables referred to in this bulletin is also
available for download from this address, along with the CSV file and the
Coroners Statistical Tool spreadsheet.
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:
Bridgette Miles
Ministry of Justice
7th Floor (7.07)
102 Petty France
London
SW1H 9AJ
Email: xxx@xxx.xx
A copy of the data collection form which was sent to coroners may be
obtained via the contact details above.

General enquiries about the statistical work of the Ministry of Justice can be
e-mailed to: xxx@xxx.xx

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

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