Speed Brief - 2024 Chief Coroner’s Report: Priorities, Challenges and Implications for Inquests and Coroners

The Chief Coroners Annual Report for 2024 was published on 11 September 2025, and contains pertinent insights into current challenges faced by the coronial service; areas where reform is required; and an indication of the current Chief Coroner, Her Honour Judge Alexia Durran’s, intentions for the future of the service. This is her first report as Chief Coroner, although she acknowledges that a significant part of the reporting period fell under the leadership of her predecessor, His Honour Judge Thomas Teague.

In this speed brief we have set out the key takeaways from the Report, and the impact of these issues on Coroners and inquest practitioners alike.

Key Takeaways

• The number of deaths reported to the Coroner has decreased, however the number of deaths requiring a post mortem report increased. The Chief Coroner reasoned that this indicates that the cases reported to Coroners are becoming more complex ( Para 2.3).
• In many jurisdictions there remains a large volume of cases lasting more than 12 months. The Chief Coroner has confirmed that “the factors impacting the ability for cases to be dealt with within a year were largely outside of the coroner’s control” ( Para 3.2). In particular, a significant proportion of those cases are reliant on external investigations such as ongoing criminal investigations and prosecutions, Health and Safety Executive and Prisons and Probation Ombudsman inquiries or Independent Office of Police Complaints investigations. Her view is that the service is becoming increasingly reliant upon the speed with which regulators are able to conduct their investigations, before the inquest can progress ( Para 3.3). This is in keeping with our observations, where police and regulators with stretched resources are continue to grapple with fatalities requiring investigation.
• Funding remains a challenge for the coronial service, and is inconsistent across jurisdictions. The Chief Coroner is concerned with the funding of judge-led inquests under Schedule 10 of the Coroners and Justice Act 2009 in particular, which are not the subject of centralised funding, and which in turn impact upon the wider coronial service in those jurisdictions where it is necessary to hold a judge-led inquest ( Para 6.51-6.53).
• There is opportunity for reform in the monitoring of Prevention of Future Deaths Reports (“PFD Reports”). The Chief Coroner acknowledges the misunderstanding by the public and the media that Coroners have powers of oversight, and that PFD Reports are akin to recommendations in public inquiries. Whilst PFD Reports are published on the Chief Coroner’s website, and there is a statutory obligation on the receiving organisation to respond within 56 days, there is no system or mechanism to oversee responses to PFD Reports. Once a PFD Report is issued, the Coroner has no legal power to take any further steps. The Chief Coroner recognises that if PFD Reports are to be given the same force as inquiry recommendations, then reform is required ( Para 4). We consider whether PFD Reports are fit for purpose with David Pojur, Barrister at Lincoln House Chambers and Assistant Coroner for North Wales, in episode 5 of our podcast series, available on our website, Spotify or Apple Podcast. We also note that there are of course concerns about whether recommendations made by public inquiries are sufficiently and appropriately adopted.
• The number of PFD Reports issued in 2024 increased, an indication of an increasing number of cases giving rise to a concern that future deaths may occur or that action should be taken to reduce the risk of death. Organisations should of course consider such PFD Reports and respond within the timeframe, unless an extension is granted by the Coroner ( Para 4.4), in recognition of the fact that a PFD Report provides an opportunity for reflection and for organisations to show a commitment to continuous improvement.
• The House of Commons Justice Committee (the “Committee”) convened a session to scrutinise the coronial service in January 2024. The Chief Coroner provides a summary of the evidence given to the Committee ( para 6), which included examples of where reform would be beneficial. Examples include inconsistencies in quality of service, and allocation of resources, which impacted the timely completion of inquests, and therefore impacted the experience of bereaved families. The Chief Coroner’s own contribution emphasised the need for unified training, clear guidance and consistent application of procedures. Following the Committee session, the former Chief Coroner wrote a letter reiterating the need for increased funding and structural reforms. The Committee’s inquiry was discontinued following the dissolution of Parliament ahead of the General Election and therefore no final report or formal recommendations were made, although the Chair of the Committee issued a letter expressing serious concern about the deficiencies in the coronial service. Whilst the Committee therefore echoed concerns held by the Chief Coroner, there is currently no forward-looking plan to implement the reform felt to be needed within the coronial service.
• Whilst the statutory medical examiners scheme was introduced on 9 September 2024, it is too soon to understand the impact of those reforms. The Chief Coroner issued guidance in an effort to encourage consistency in its implementation ( Para 6.15-6.19). It remains to be seen how that guidance will be put into practice across the country.

A forward look

• Identifying challenges and delays: The Chief Coroner has confirmed her intention to ask all jurisdictions to provide the estimated number of cases they expect may take over 12 months to conclude, so that she can engage with those jurisdictions on the challenges faced by that particular area. She will continue to scrutinise those figures.
• Standardisation in guidance and training: The Chief Coroner has committed to reviewing and updating all of the existing Chief Coroners guidance, including the relevant guidance for “service deaths”. The Chief Coroners Bench Book was also published in January 2025, as a resource for Coroners, practitioners and the public. The Chief Coroner is working with course directors to make improvements to training generally, and ensure there is one annual training event for new Assistant Coroners.
• Standardisation in service: The Chief Coroner hopes to implement a standardised portal referral for areas where police forces and NHS organisations overlap across a number of Coroner areas. Further, an out of hours rota system will be available in all Coroner areas.
• Regional Leadership Coroners have been appointed to increase regional co-operation and support, along with a lead Coroner for wellbeing and a lead Coroner for diversity and inclusion. 

The insights and challenges identified by the Chief Coroner in this latest report may not come as a surprise to Coroners and inquest practitioners alike, and the real impact of the issues lies in delays in inquests, and distress to bereaved families. The Chief Coroner has set out her proposals for managing the service and ensuring standardisation across jurisdictions, but it is clear that there are issues which are outside of her control, and which may warrant wider reform, which has arguably already been under discussion for far too long.

Should you wish to discuss these insights in more detail, or how we can help with inquest management, please do contact us.