The Chief Coroner has recently published his annual report on the performance of coroners’ services across England and Wales. This year’s report highlights falling referral numbers, increasing case complexity and ongoing efforts to improve consistency across the coronial system. This article looks at the key takeaways for healthcare providers.

Caseloads and Inquest Timelines

Although fewer deaths were referred to coroners in 2025, many investigations are becoming more complex, particularly those involving specialist medical evidence or related criminal investigations.

• 147,814 deaths were reported to coroners in 2025 – down 15% compared with 2024.
• The average time taken to conclude an inquest remained stable at 31 weeks.
• Coroners still aim to complete inquests within 12 months of the death.

The main cause of delays continues to be waiting for other organisations, such as the police, HSE and specialist investigators, to complete their enquiries before the inquest can proceed. The report also suggests that the introduction of the statutory Medical Examiner system in September 2024 may be contributing to fewer referrals by improving scrutiny of deaths and ensuring only appropriate cases are referred to coroners.

What this means for healthcare providers:

• Investigate incidents as early as possible.
• Identify and support key witnesses promptly.
  Ensure records and evidence are retained for potentially lengthy investigations.
• Monitor how Medical Examiner scrutiny is affecting referrals and communications with coroners.

Prevention of Future Deaths Reports (PFD)

PFD reports remain a significant feature of the coronial system and continue to present both governance and reputational risks for organisations; 647 PFD reports were issued in 2025 – down from 707 in 2024. The Chief Coroner continues to publish details of organisations that fail to respond to PFD reports. However, the report reiterates that coroners identify risks rather than regulate or oversee the implementation of recommendations.

What this means for healthcare providers:

• Have clear processes for recording, monitoring and responding to PFD reports.
• Ensure responses are provided within the required timescales.
• Recognise the reputational risks of failing to engage with the PFD process.

Recruitment, Training and Standardisation

The report highlights continued efforts to improve consistency across coroner areas through national leadership, training and recruitment initiatives. Key developments include:

• Appointment of Regional Leadership Coroners to support good practice and recruitment.
• New national leads for well-being, diversity and inclusion.
• A standardised annual recruitment process for assistant coroners.
• National training for Coroners’ Officers on a two-year cycle.
• A review of the model coroner area, with new guidance expected by May 2027.

These changes aim to deliver a more consistent experience for families and interested persons across different coroner areas.

The Hillsborough Bill

The report directly references the new proposed Public Office (Accountability) Bill, which has the potential to significantly affect inquests involving public bodies. The Bill includes proposals for:

• A stronger statutory duty of candour.
• New criminal offences for misconduct in public office.
• Greater access to legal aid for bereaved families where public authorities are involved.

The Chief Coroner notes that any new statutory duty should be clearly drafted so that it supports, rather than delays or complicates, the coronial process.

What this means for healthcare providers: Public bodies and healthcare organisations should monitor the progress of the Bill closely and consider its potential impact on investigations, disclosure obligations and participation in inquests. Our team can help keep you up to date.

You can find our recent article about the Bill and its journey through Parliament here.

Chris Newton - Partner

E: cnewton@keoghs.co.uk

Adele Fletcher - Senior Associate 

E: adelefletcher@keoghs.co.uk