The Office of the Chief Coroner was established in 2014 after new legislation to introduce the role. You can read more about that role on the Chief Coroner’s website.
You can also search for Preventing Future Death reports but if you want to see a selection of those which are relevant to the topics on this website, there is a resources page with the most important ones.
This post is merely to provide links to the annual(-ish) reports which are published. They are very interesting, both on the challenges faced by coroners and their frustrations, as well as coverage of themes arising from the Preventing Future Death reports which are published each year. There are in the region of 400 PFDs issued each year and whilst organisations have a statutory duty to respond to a notice, there is no duty to implement the recommended changes His Majesty’s Coroners suggest are required.
I have mixed views about that. There are a number of inquests, including somewhere I have given evidence as an expert witness, where PFDs seemed very sensible from my perspective and where police forces, ambulance services or NHS trusts have not implemented the changes highlighted in the various matters of concern in PFDs. Equally, I have seen PFDs from Coroners where I think they are asking for things which are not necessary or just unworkable. It’s a fascinating area of public policy, but it’s even more important to remember every inquest involves a loss of human life with family and friends linked to the person who died and often with professionals who were connected to the events or the background giving rise to their death.
The annual reports relate to all of the work by HM Coroners, not just those on policing, mental health or criminal justice. But for what interest or worth they may be to you, here are the Annual Reports —
- Extraordinary Report: 10 years post-reform
- Chief Coroner’s combined report for 2021-22
- Chief Coroner’s combined report for 2018-19 and 2019-20
- Chief Coroner’s Annual Report 2017-18
- Chief Coroner’s Annual Report 2016-17
- Chief Coroner’s Annual Report 2015-16
- Chief Coroner’s Annual Report 2014-15
- Chief Coroner’s Annual Report 2013-14
You can read an extraordinary report: 10 years post-reform.
I’ll try to remember to update this page when subsequent reports are published each year.
Winner of the President’s Medal, the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown, 2024
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 