The Chief Coroner’s Annual Report for 2025 has now been published – what healthcare providers can expect

The Chief Coroner makes an Annual Report to the Lord Chancellor each year, summarising the work, priorities, concerns, and other matters relating to coroners services nationwide.

Headlines

• 147, 814 deaths were reported to a coroner in 2025, representing a reduction of 15% from 2024.
• However, despite the fall in absolute numbers of cases, coroners across a number of areas have reported increasing case complexity particularly in investigations involving specialist medical or linked criminal inquiries. This matches our experience of representing clients in healthcare inquests. 
• The target time for completion of an inquest is within 12 months of the death. In 2025, despite the increasing complexity, the average time required to complete an inquest has remained stable at around 31 weeks (7 months).
• The most common reasons for inquests being delayed beyond 12 months remains reasons outside the control of the coroner including reliance on other agencies completing their investigations - primarily those of the police, Health & Safety Executive, Prison & Probation Ombudsman, Independent Office of Police Complaints, and specialist accident investigation bodies. Coronial legislation requires that inquests be paused to allow specialist or possible criminal investigations to take place first. We recommend that early investigation takes place including identification of witnesses to avoid issues later down the line as a result of such delays.
• It is possible albeit uncertain this fall in number of referrals is influenced by the statutory medical examiner system, introduced in September 2024. Early feedback suggests improved consistency in the scrutiny of “natural causes” deaths and greater clarity in referrals to coroners.
• Healthcare providers especially Trusts within whom Medical Examiners are hosted should consider monitoring how ME scrutiny influences the deaths referred to coroners as well as the clarity of information provided at the point of referral. 
• We can also expect the more complex healthcare-related inquests to remain lengthy and healthcare providers should ensure that their processes around incident investigation, document retention, witness support, and governance oversight are capable of managing coronial investigations which can continue for years. 

Prevention of Future Deaths

• 647 Reports to Prevent Future Deaths (‘PFD reports’) were issued in 2025, a decrease on 2024 (707) but an increase on 2023 (550). This represents general consistency in the high numbers of such reports in the last few years. 
• The Chief Coroner continues to publish a ‘name and shame’ list of organisations which have not responded to a PFD report and which have not requested extensions to respond. However, the Chief Coroner also stressed that the role of the coroner is judicial and is limited to identifying risks; they are not regulators and will not supervise mitigation of that risk. 
• This is a useful reminder that PFD reports create not only an obligation to respond but reputational risks for not doing so. Healthcare organisations should build into internal governance clear processes for noting, tracking and responding to PFD reports to avoid these risks. 

Recruitment, training, and standardisation

• Coroners services have always been local to their particular areas, with funding and appointments usually made through the local authority. However, since the creation of the national Chief Coroner’s role there has been a trend towards more national oversight and management in some areas. Regional Leadership coroners have been appointed to support the Chief Coroner, to help support local coroners through sharing good practice, sharing insight, and assisting judicial recruitment processes.
• There are also new lead coroners for wellbeing and diversity and inclusion. The report emphasises that coroners’ services have unusual governance structures compared to other jurisdictions due to being connected to local authorities rather than national tribunal bodies.
• The report notes that a significant number of new senior, area, and assistant coroner posts were made in the 2025. Changes have been made to recruitment of assistant coroners so that there is now a standard, staged annual process, increasing transparency and expectations.
• Coroners’ Officers will now be given national standard training on a two-year cycle.
• The Chief Coroner’s Office has begun a review of the ‘model’ coroner area to further promote standardisation of service structure across coroner areas; this is expected to be published as guidance by May 2027.

The Hillsborough Bill 

• The new Public Office (Accountability) Bill presently before the House of Lords (having passed the Commons in July 2026) has the potential to significantly reshape the inquest field through an enhanced statutory duty of candour, new criminal offences for misconduct in public office, and greater parity of arms via legal aid funding for families where a public authority is an interested person.
• The Chief Coroner’s report directly addresses the new proposed legislation and in particular notes the need for any new statutory duty to be “clearly framed so that it supports, rather than complicates, the effective and timely delivery of coronial functions.”
• You can read more about the Hillsborough Bill in our article here. 

At Clyde & Co, we have a team of experienced inquests lawyers who attend inquests every week. Please get in touch if you would like to find out more about what we offer.

Clyde & Co's healthcare group is recognised for its extensive industry knowledge, offering a range of legal services covering public and private sectors as well as inquests, advocacy, professional regulation, product liability and pharmaceuticals/life sciences. Should we be able to assist you, please do contact one of our experts.