More Data on Death: Coroner Statistics Annual Bulletin for 2021

Today, the Ministry of Justice published the most recent Coroners Statistics Annual Bulletin. It covers deaths between January and December 2021 and therefore, as last year, the effects of the Covid pandemic can still be seen throughout.

The Bulletin remains a useful guide on the workload of coroners around the country and can be used to identify patterns and trends in inquest conclusions and times taken for cases to be heard.

This post sets out key figures from the bulletin.

Key figures from the Bulletin:

  • Overall, one third (195,200) of all registered deaths were reported to coroners. This is the lowest level since ONS began collecting annual data in 1995, and down 5% on 2020.
  • There were 580 reports of deaths in state detention an increase of 3% on last year, mostly a reflection of more deaths in prison.
  • 32,800 inquests were opened, a slight increase on 2020 with unsurprisingly 4% more inquests actually concluded than in 2020
  • Conclusions of suicide increased by 8%, with suicide remaining far more common in males.
  • Delay: The average time taken to complete an inquest was a month longer than in 2020, at 31 weeks.
  • Preventing Future Deaths: For the first time, the Bulletin records the number of Preventing Future Deaths (‘PFD’) reports issued, 440 PFD reports were made in 2021.

Fewer deaths reported to coroners

Unsurprisingly given the pandemic, 2021, saw the second highest number of registered deaths in England and Wales since 1995, with only the figure for 2020 being higher.

However, many of these additional deaths were from natural causes with the effect is that proportionately fewer deaths needed to be reported to coroners. It is this phenomena which explains why in 2021, the  33% of deaths reported to coroners is the lowest proportion since 1995.

Another pandemic driven statistical skew is the huge increase in jury inquests as pandemic restrictions lifted.  Coroners managed to successfully complete 428 Jury inquests in 2021.   Compared to an all-time low of 239 in 2020. Indeed the surprise may be that even in the height of a pandemic so many coroners managed to hear so many jury inquests.

Highest level of deaths in state detention since reporting began

Sadly, there were 18 more reported deaths in state detention than the previous year, with 580 deaths being reported. The increase reflects an additional 55 deaths in prison compared to last year, with a total of 373 death reported from prison.

That increase is thought to be, largely driven by deaths from covid-19 within the close contact prison environment. It is hoped that this will be explored as part of the planned Covid Inquiry.

Deaths  in police custody more than doubled on last year increasing, by 10, deaths to a total of 18.

As ever, it would have been helpful if the MoJ had provided a breakdown of how those who died in state detention came by their deaths. This would enable further analysis, on whether suicide or self-inflicted deaths in prisons are increasing or decreasing, which is important as part of the state’s ongoing Article 2 ECHR obligations. However, this data has not been provided.

In its absence, other data sources can be analysed, including the quarterly “Safety in Custody” statistics produced by the MoJ. However, these statistics use different reporting periods, with the most recent version covering up to March 2022. In the 12 months to March 2022, there were 75 self-inflicted deaths in prison, which is a decrease of 5 of the previous year.

Fewer detained patients are dying

One of the more positive changes in the Bulletin, however, is the significant reduction in deaths of patients detained under the Mental Health Act 1983 (“MHA”).

There were 170 deaths of people detained under the MHA in 2021, a 22% decrease (49 cases) compared to 219 deaths in 2020.

Again, the Bulletin does not provide any analysis as to the reasons behind the reduction and it does not reveal how the 170 people who died in psychiatric detention in 2021 came by their deaths.

Suicide is at its highest level since reporting began

Sadly, deaths by suicide have also increased. Overall, a conclusion of suicide was reached in 4,820 inquests in 2021. This marks an 8% increase on 2020, in which 4,475 suicides were recorded.

How much of this is the filtering down of the Maughan decision remains to be seen although with suicide being at its highest level since reporting began in 1995, it may be that again the impact of the pandemic has a lot to answer for here.  As has always been the case, men are far more likely to die by suicide, with 3,596 men dying by suicide, as opposed to 1,224 women.

Other conclusions

Those who practice in coronial law will be well-versed in the other short form conclusions often considered by coroners. In terms of the headline figures for other conclusions on how people came by their deaths:

  • Drug and alcohol related deaths increased by 50, from 3,840 to 3,890.
  • Deaths by industrial disease declined significantly from 2,632 to 2,100.
  • The number of people found to have been unlawfully killed rose dramatically from 61 to 101. It is thought that could be, in part, explained by the deferral of complex, jury inquests during the pandemic.
  • 7 people were recorded as having been lawfully killed, an increase on 5 in 2020.
  • Deaths from self-neglect also increased and 35 such deaths were recorded in 2021.
  • Road traffic collisions were deemed responsible for 820 deaths.
  • Natural causes findings were returned for 3,672 deaths.
  • The number of stillbirths recorded also decreased to 3. This is down from the all time high of 21 reported in 2007.
  • Open conclusions, which Chief Coroner’s Guidance Sheet No.17 discourages “save where strictly necessary,” and which tend to be used where no other conclusions can safely be reached on the evidence, decreased to 1,052.

How much weight can be put on any of the above figures though must be questionable, given that the statisticians make no attempt to classify the 24% of inquests that end with a narrative conclusions and so are not taken into account for the data above.  Indeed it seems that even a very short but non-standard conclusion will be left out of the number crunching by ONS.

Average time to complete an inquest increases

The bereaved continue to have to wait longer for inquests to be on average it will now be 4 weeks longer than in 2020 when the delay already was 6 months.  This may well reflect the unprecedented challenge at the height of the pandemic, although something of a postcode lottery is observed: the average time taken for cases to be heard varies dramatically across the country.

Inner South London had, by far, the biggest backlog at 75 weeks. With a 66 week average wait in Gwent in Wales. By contrast in Liverpool and in the Black Country cases are heard impressively rapidly with an average wait of 11 weeks. Perhaps the ever-pressed coronial areas with the biggest backlogs can make use of these statistics when making the case for further resources from their local authorities.