The Chief Coroner’s report to the Lord Chancellor (2015/2016)

Executive summary The outgoing Chief Coroner, Judge Peter Thornton QC, published his annual report to the Lord Chancellor on 15 July 2016.

Executive summary

The outgoing Chief Coroner, Judge Peter Thornton QC, published his annual report to the Lord Chancellor on 15 July 2016. He made a number of recommendations in the report in terms of potential reform of the coroner service. He commented on the recent positive developments in the service and made a number of recommendations for legislative reform.

In detail

In the long-term the Chief Coroner has supported calls for a national coroner service, to promote standardisation and consistency within the process. In the shorter term he has prepared a draft blueprint document entitled ‘A Model Coroner Area’ (an aspirational document for the coroner service in its present local structure). It is hoped that this document will generate further thinking and discussion about how a coroner area should function and how it can best serve the public.

The Chief Coroner has praised the reduction of delays and noted the number of cases not completed or discontinued within 12 months has greatly reduced since the introduction of the standard procedure for reporting to the Chief Coroner (on cases over 12 months old). He also noted the average time of all cases from death to inquest has fallen considerably by 28.6% (from 28 to 20 weeks). He praised the number of further appointments of senior coroners and assistant coroners, the expansion of training people in coroner work and the release of further guidance and advice, which he found increases consistency.

He indicated his continued support for a new scheme to regulate the number of second post-mortem examinations in the case of suspicious deaths. The proposal seeks to restrict additional post-mortem examinations to cases where there is a good and reasonable justification for them. He indicated his concern for the dwindling number of pathologists and recommended there would be ideally be a regional centre, with an on-duty pathologist.

He was critical of there currently being no statutory or other clear criteria for medical practitioners reporting deaths to coroners which he said has created uncertainty and inconsistency. He recommended the introduction of statutory guidance for reporting deaths to the coroner.

With regard to legislative reform, the Chief Coroner recommended reform in relation to the following issues:

  1. Deprivation of Liberty Safeguards cases (DoLS).
  2. Mergers of coroner areas.
  3. Discontinuance without a post-mortem examination.
  4. Inquests without a hearing.
  5. Fresh inquests.
  6. Deaths at sea (body not recovered).
  7. Representation for families.


This is the third annual report of the Chief Coroner to the Lord Chancellor. In the opinion of the Chief Coroner, significant progress has been made across England and Wales. He is of the view that statutory reforms and the first Chief Coroner’s reforms have been effective, positive and in the public interest. Judge Thornton stepped down as Chief Coroner at the end of September 2016. The new Chief Coroner (with effect from 1 October 2016) is Judge Mark Lucraft QC.

View the Chief Coroner's report


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