Coroners are required to notify the Chief Coroner of any investigation that lasts more than a year and to notify the Chief Coroner of the date on which any such investigation was subsequently concluded. 2.3 Investigations If asked to do so by a prosecuting authority because someone may be charged with a homicide or related offence involving the death of the deceased (paragraph 1); Coroners in England and Wales have continued to provide the data which is the basis of these statistics and proactively engaged with statisticians to ensure this report was produced in a timely manner and to high standards. This publication includes the number of deaths with a conclusion of suicide recorded at inquest - statistics on suicide deaths are also published by the ONS [footnote 4]. The ‘ONS Suicide Statistics UK’ series uses the national statistics’ definition of suicide: deaths given an underlying cause of intentional self-harm or an injury/poisoning of undetermined intent. In 2016, this definition has been modified to include deaths from intentional self-harm in 10- to 14-year-old children in addition to deaths from intentional self-harm and events of undetermined intent in people aged 15 and over. 1.7 Users of the statistics In 2021, 908 finds were reported and 229 inquests were concluded. There were no inquests held into Treasure Trove in 2021 (relating to finds made before the Treasure Act 1996 came into force), although it is likely that a few such inquests will continue to be held from time to time.

Information on the quality and consistency of the Coroners statistics can be found in the supporting document published alongside this bulletin. 1.1 About the statistics Marshall’s mother Jane Ireland was a mum of three. Her family describe her as a fun and loving person who brightened every room she walked in to. She was a talented makeup artist and worked on theatre productions and photoshoots. She was also a qualified Reiki therapist and dreamed of opening a retreat.The quality statement published with this guide sets out our policies for producing quality statistical outputs for the information we provide to maintain our users’ understanding and trust. Caution should be taken when making comparisons between regions of the coronial activities – post-mortems, inquests, timeliness, due to the restrictions based on the tier system around the country. Local authority set-up, resource, facilities and socio-economic make up mean this will not be comparing like with like.

A post-mortem examination will often be held before the coroner decides whether to open an inquest. In 2021, 55% of deaths reported to coroners which eventually led to an inquest involved a post-mortem, no change on 2020. The coroner found that Jane’s mental health had been stable with no major relapse. The family strongly disagree with this finding, which fails to reflect the evidence heard at the inquest. Holly was raising serious concerns about her mum’s mental health in March, April and October 2019 and there were concerns raised by professionals in June and July 2019. Once statistics have been designated as National Statistics it is a statutory requirement that the Code of Practice shall continue to be observed. There were 94,004 deaths reported to coroners where there was neither a post-mortem nor an inquest. This type of case has decreased by 14% in the current year and the number of cases reported is the lowest level since 2000. This continues the decreasing trend seen since 2017. The proportion of all deaths reported where there was neither an inquest nor a post-mortem examination has decreased by five percentage points to 48% in 2021. This proportion has been declining since 2018.For somebody of Nicola’s size, it would have taken one or two breaths of water to be a lethal dose.” Coroners’ inquisitions are also in KB 13 and KB 140. They include a significant number of items from the mid to late 18th century, although the practice of forwarding all inquisitions to the King’s Bench appears to have fallen into disuse in the early 18th century. INQUEST is the only charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. The proportion of deaths reported to coroners in England and Wales continues to fall. 2021 recorded the second highest number of registered deaths in England and Wales since 1995 (the highest being in 2020), largely due to the continued impact of Covid-19. However, deaths reported to Coroners, which form only a proportion of all registered deaths, decreased to their lowest level since 1995.

The Care Quality Commission (CQC) annual report on Monitoring the Mental Health Act can be found here: http://www.cqc.org.uk/content/monitoring-mental-health-act-report. ↩ All official statistics should comply with all aspects of the Code of Practice for Official Statistics. They are awarded National Statistics status following an assessment by the Authority’s regulatory arm. The Authority considers whether the statistics meet the highest standards of Code compliance, including the value they add to public decisions and debate.

The post-mortem examination reveals that the deceased died of natural causes but the coroner considers that it is necessary to (investigate or) continue the investigation. The coroner must then hold an inquest.

The coroner found that other alternative placements had not been considered and that Children’s Social Care had not been involved in the discharge planning, as they should have been. The expert described the discharge into Jane’s care as abrupt, precarious and inappropriate without considering alternative placements. The Coroner Service: Government Response to the Committee’s First Report - Justice Committee - House of Commons (parliament.uk) ↩

Reporting treasure finds to the coroner

However, Jane was not flagged up as a risk in need of more intensive support. Instead, her daughter Holly was left repeatedly trying to access help for her. Her attempts were ignored and concerns went unrecognised. The family are disappointed that the coronial process has reflected the approach of healthcare professionals while Marshall and Jane were alive, in failing to take their concerns seriously. In England and Wales a coroner also handles investigations regarding finds reported to them under the provisions of the Treasure Act 1996. The coroner will inquire into any treasure which is found in their area and establish the identity of the finder. By law, all treasure finds must be reported to the coroner within 14 days except where treasure finds occurred before 24 September 1997 when the find is dealt with under common law “Treasure Trove”. Such cases are extremely rare and the vast majority of cases fall under the Treasure Act 1996.