Key analysis

  • Of roughly 500,000 deaths in England and Wales:
  1. 241,211 were reported to coroners in 2016 – the highest figure to date;
  2. 40,504 of the reported cases required investigation – very much higher than other comparable jurisdictions;
  3. 11,300 involved a deceased subject to Deprivation of Liberty Safeguards (automatic referral no longer needed since 3 April 2017, which will reduce this statistic in future); and
  4. 576 inquests held with juries – a 26% increase since 2015.
  • 375 Reports to Prevent Future Deaths were issued. An analysis of reports of deaths in prison identified some common themes around awareness and consistency in application of procedures, failure to pass on information, estate issues and training.
  • A number of concerns are carried forward from the third annual report of 2015-16, including: the need for clear statutory guidance for medical practitioners on reporting deaths to the coroner; lack of control, funding and oversight of pathology services; and the impact of the proposed system of Medical Examiners (“MEs”).
Key recommendations
  • Consideration of exceptional funding for legal representation for families where the state has agreed to provide separate representation for one of more interested persons.
  • Extending a coroner’s power to discontinue an inquest to situations where there is no post mortem examination, if the cause of death is discovered by other means, for example medical records.
  • Inquests to be concluded without a hearing in appropriate circumstances and a written ruling given.
  • Extending the High Court’s powers when quashing an inquest to include amending the record of the inquest.
Our view

The upward trend in inquests continues and reflects our own experience of the last few years. We have noticed this consequential increased burden on the coroners’ support services resulting in less organised/ part-heard hearings in many areas, which in turn increases resourcing pressures on organisations and their staff to attend inquests on more than one occasion.

To a large extent, the Chief Coroner’s concerns and recommendations mirror those in the second and third annual reports. He remains concerned about the implications of the ME system. We await further guidance on the implementation of the ME system and whether the concerns raised by the Chief Coroner will be allayed.
The Chief Coroner also reiterates his predecessor’s recommendation for the Exceptional Funding Guidance (Inquests) to be amended. Whether this repetition results in the changes sought remains to be seen. In the current economic climate, we suspect the government is unlikely to see addressing this as a priority despite this being the second request for the change.

How Capsticks can help

Capsticks is a market leader in the healthcare and inquest field and is ranked in the top
tier for inquests and clinical negligence work by the Chambers Guide to the Legal profession and the Legal 500. If you require inquest representation or would like to discuss any inquest related issues please contact: Philip HatherallGeorgia FordTracey Lucas or Ian Cooper.