Data on Death: Coroner Statistics Annual Bulletin 2019

Ministry of Justice/ONS, 14.5.2020

On 14 May 2020, the most recent Coroners Statistics Annual Bulletin was published. At a time when data on death dominates the news, the Bulletin may have passed inquest practitioners by. However, the Bulletin remains a useful guide on the workload of coroners around the country and can be used to identify possible trends for the future.

It is important to note that whilst the Bulletin was published in May 2020, it covers the period from January to December 2019 and therefore it does not cover any Covid-19 related deaths. Such deaths will not be included in the Bulletin until its next publication date in May 2021.

Key figures from the 2019 Bulletin:

  • 40% of all registered deaths were reported to coroners in 2019;
  • Overall deaths in state detention are down 7%, driven largely by a 16% fall in deaths of individuals under the Mental Health Act 1983;
  • Overall, conclusions of suicide increased by 11%;
  • Average time taken to process an inquest rises to 27 weeks.

Fewer deaths reported to coroners, more inquests opened

In 2019, the total number of deaths reported to coroners stood at 210,912, a 4% decrease on the 2018 figure. This 4% decrease in reported deaths should be viewed in the context of an overall 2% fall in all ONS registered deaths.[1]

Further, in 2019, the proportion of all deaths reported to coroners is at its lowest level since 1998 – at 40%. This proportion is very similar to the 2018 figure (of 41%) despite the fall in the total number of all deaths in 2019.

From 2005 to 2016, the proportion of deaths reported to coroners was actually much higher, but this was, in part, due to the change in 2017, where it was no longer a requirement to report to a coroner the death of a person under a DOLS authorisation. The similarity between the 2019 and 2018 figures may suggest that the proportion of deaths reported is likely to settle at a lower rate.

Perhaps what is of most interest is that of those deaths reported to a coroner, a higher proportion are leading to an inquest. In 2019, just under 30,000 inquests were opened – a 3% increase on 2018, which might simply reflect that a greater proportion of reports to a coroner are appropriate and so trigger the s.1 CJA investigatory duties.

Further, jury inquests are on the increase. Jury inquests were up to 527 in 2019, compared to 423 in 2018.

Fewer deaths in state detention overall

Overall, a welcome change is seen in the Bulletin for deaths in state detention. Such deaths are down by 7% on the previous year. In 2019, there were 478 deaths in state detention compared to 514 in 2018. This decrease appears to be due to a fall in deaths of those detained under the Mental Health Act 1983 and of those in prison.

Prison deaths decreased slightly by 5% to 299. Although the number of prison deaths has fallen in 2019, it is still the second highest number since 2011. A record number of 316 prison deaths were reported in 2018.

Somewhat frustratingly, the Bulletin does not breakdown how those who died in prison came about their deaths nor does it compare the prison deaths with the prison population. The UK Prison Population Statistics are of some assistance in this regard. The prison population had increased to 82,771 as of December 2019 and stood at 82,148 in December 2018. Therefore, the reported decrease in prison deaths in 2019 combined with a slight increase in the prison population over the period means that a real decrease in prison deaths has taken place which is a welcome change.

It is a shame that the Bulletin does not include data on inquest conclusions for deaths in detention as this makes it much harder to see annual trends. However, the MoJ continues to produce quarterly reports through its “Safety in Custody” statistics. On 30 April 2019, the MoJ released the latest statistics, which show that there were 80 self-inflicted deaths in the 12 months to March 2020. This is a fall from 2018, however it is higher than the figure of 73 self-inflicted deaths in 2017.

Additionally, whilst deaths in police custody fell very slightly from 15 to 14, deaths in immigration removal centres sadly increased – from zero in 2018 to 2 in 2019.

Whether deaths in custody will increase in the 2020 Bulletin as a result of the Covid-19 pandemic remains to be seen and is something the authors of the next Bulletin should be alert to. Given the importance of Article 2 inquests and the public interest in understanding any patterns or trends related to deaths in custody, including further MoJ/ONS analysis on these deaths would be a very welcome change to the Bulletin.

Fewer detained patients are dying

One of the most notable changes in the Bulletin is the continued reduction in deaths of patients detained under the provision of the Mental Health Act 1983 (“the MHA”).

There were 144 deaths of individuals subject to MHA Detention in 2019, a 16% decrease (27 cases) compared to 2018. This reflects a year on year fall since 2016. Similar statistics are published by the Care Quality Commission (CQC) in their annual report, however different reporting mechanisms are used.

The Bulletin does not provide any analysis as to the reasons behind the reduction and it does not reveal how the 144 people who died in psychiatric detention in 2019 came about their deaths.

Increase in suicide as cause of death

Overall, a conclusion of suicide was reached in 4,620 inquests in 2019. This marks an 11% increase on the previous year in which suicide was the conclusion in 4,166 inquests. The media have made headlines from this finding and the statistically significant increase serves to bolster calls for increased mental health support across the country. However, it may well be that this does not reflect a true change in the national rates of self-inflicted death – but rather is the continuing effect of the lowering of the standard of proof for suicide, following the decision in Maughan[2] (see our earlier blog here).

Men more likely to die in circumstances that lead to an inquest

In 2019, male deaths accounted for 56% of all deaths reported but accounted for 65% of all inquest conclusions. This suggests that, overall, males are more likely to die in circumstances that lead to an inquest.

Males are also far more likely to die because of suicide with men accounting for 77% of suicide verdicts in 2019. The same can be said of death by industrial disease with men accounting for 91% of such deaths in 2019.

Regional Variation

A huge regional variation can be seen in the Bulletin on a number of data points.

Regional differences can be seen when considering conclusions by coroner area. The highest number of drugs and alcohol related deaths took place in the North West at 526. The highest number of suicides were reported in the South East at 781.

A wide variation between coronial areas is observed when considering the inquests opened as a percentage of the deaths reported. Nationally 14% of all deaths reported to coroners went on to an inquest and, for most coroner areas, this figure fell somewhere between 10 and 20%. However, in Newcastle upon Tyne only 6% of deaths reported to a coroner led to an inquest. This can be contrasted with 26% of deaths in the City of London.

Average time to complete an inquest increases

Of continued concern for bereaved families, however, is that the average time to complete an inquest has risen again, to 27 weeks. This figure stood at 26 weeks in 2018. An average wait of over six months for an inquest is likely to be extremely difficult for bereaved families and it is discouraging to see this figure increase. Again, wide regional differences were observed with North Tyneside managing an average of 8 weeks and the City of London taking an average of 50 weeks to complete an inquest.


Overall, the Coroners Statistics Annual Bulletin provides useful information to inquest practitioners. It provides a high-level summary that can be used to identify possible patterns and trends.

For the future, however, the authors of this blog suggest that more data should be provided on deaths in custody and patients detained under the MHA. Presently readers need to access other datasets in order to gain an understanding of how those who die in detention come about their deaths. Given the importance of Article 2 inquests and the public interest in understanding any patterns or trends related to deaths in state detention, the inclusion of further data on these deaths would be a very welcome change.

Finally, we consider that the Covid-19 pandemic will pose new challenges for the MoJ in the drafting of the 2020 Bulletin. Whilst the delay in holding inquests will mean the data set will be incomplete, the authors of the 2020 Bulletin could consider including:

  • A new section on Covid-19 related deaths. Without separation, many Covid-19 deaths would be subsumed under the ‘natural causes’ section; furthermore cases where a Covid-19 is contracted in the workplace should be of particular note.
  • Demographic breakdown of the Covid-19 related deaths and analysis on where these deaths took place (including hospitals, care homes and prisons);
  • Data that specifically considers deaths reported during the lockdown period – with focus upon any increase in suicide or domestic homicide.

This type of data may help to ensure that the effects of the Covid-19 pandemic are reflected in the Coroners statistics.



[1] Provisional figure based on ONS monthly death registration figures for 2019

[2] R (Maughan) v Senior Coroner for Oxfordshire, the Chief Coroner as intervenor (and INQUEST as an interested party) [2019] EWCA Civ 809.