Coroners are judges, not regulators: Key takeaways for healthcare providers from the Chief Coroner's 2025 Annual Report

The Chief Coroner’s Annual Report for 2025 has been published. Important steps forward have been taken to strengthen national consistency and keep bereaved families front and centre at inquests but there remains work to do done.

The Report offers an important reminder that coroners are not regulators. While 647 Prevention of Future Deaths reports were issued last year, coroners have no power to enforce the changes they identify or monitor implementation. The responsibility for learning sits with organisations themselves. For healthcare providers, that underlines the importance of effective governance, thorough incident investigations and a culture that turns coronial findings into meaningful improvements in patient safety. With PFD reports remaining at historically high levels and increasing focus on national consistency, organisations should be reviewing not only how they respond to coronial concerns, but how they evidence learning from them.

Delays and system pressures

While important steps forward have been taken, the report describes the service as still being under continuing long term pressure from uneven local resourcing and consistency - continued difficulties relating to Coroner officer staffing, mortuary provision and pathology capacity. Also, being increasingly dependent on external agencies who are conducting their own investigations causing suspensions of inquests pending investigation outcomes - and the knock on effect of all of these on bereaved families and coronial staff.

The medical examiner system is already having an impact

The report specifically notes that the statutory medical examiner system, introduced in September 2024, is likely to have influenced referral patterns.

All non-coronial deaths are now subject to independent medical examiner scrutiny, creating a clearer distinction between the roles of medical examiners and coroners and reducing referrals driven solely by technical certification requirements. Medical examiners are increasingly acting as an early patient safety and governance checkpoint, with greater opportunities for bereaved families to raise concerns and for issues relating to care quality to be identified before a matter reaches the coronial system.

Fewer deaths referred, but investigations are becoming more complex

There were 147,814 deaths referred to coroners in 2025, a reported 15% reduction from 2024, yet coroners report increasing complexity, particularly in cases involving specialist medical, forensic and criminal issues. The average time to conclude an inquest remains around 31 weeks.

More PFDs are being issued

Despite the fall in deaths referred, PFD numbers remain significantly higher in 2024/ 2025 (707/ 647) compared with 2023 (550).  This supports a broader trend that coroners continue to identify systemic learning opportunities across healthcare, prisons, policing, social care and other sectors.

There is increased focus on transparency and consistency of PFDs with the Chief Coroner reporting new PFD templates, updated publication policies, greater focus on redaction practices and efforts to improve national consistency and transparency. Greater consistency may make emerging national themes easier to identify and learn from.

The Chief Coroner continues to publish lists of organisations that fail to respond to PFD reports within the statutory timeframe so robust internal systems exist to track, escalate and respond promptly to PFD reports continue to be important. At the point of publication of the report, the list identified 23 reports issued in 2025 for which one or more responses were outstanding. By comparison, the 26 reports identified in 2024 covered a six-month period only, whereas the 23 outstanding reports in 2025 relate to the full year.

Coroners are judges not regulators

One of the strongest passages in the report is the Chief Coroner's statement that:

• Coroners are judges, not regulators. The report reiterates that coroners do not make recommendations, cannot direct action, and cannot enforce learning once a PFD is issued.

• There remains no statutory mechanism to oversee implementation of learning from PFD reports.

This reiterates the ongoing question/ debate of how organisations demonstrate learning and improvement when there is no central body responsible for monitoring implementation of coronial concerns.

Hillsborough Law

The Chief Coroner notes how she told the Bill Committee that many of the principles underpinning the proposed duty of candour are already embedded within the coronial system. She stressed the importance of judicial independence, transparent fact-finding through inquests, cooperation by public bodies, and ensuring that any new legal obligations complement existing coronial functions rather than create additional barriers or delay.