Inquests: What’s on the horizon for 2026?

These are the key issues we will be keeping an eye on in 2026:

1)   Increased scrutiny of Prevention of Future Deaths (PFD) reports & their compliance 

Coroners Statistics 2024 (published on 8 May 2025) and PFD reports provide a useful overview of Coroners’ Courts trends and areas of focus for Coroners over the past 12 months together with insight into where things are heading.

Likely areas of focus:

The 2024 statistics show that, despite reported deaths falling to 174,900 (from 195,000 in 2023 and to the lowest level since 1995) and the number of inquests opened dipping 1% (to 36,700), the number of PFD reports being issued rose 25% (to 713) [gov.uk].

Highlighting ongoing particular areas of concern, of those 713 reports:

• 34 were linked to care homes and 20 to community health care and emergency services, with a significant increase in those related to the former
• Detention deaths increased 11%, driven by prison deaths
• There are increasing numbers of PFD reports that identify a complete lack of or inadequate internal investigations into the death.

Recent research indicates that Coroners’ recommendations following maternal deaths are ignored/ poorly responded to. In light of these, and the multiple maternity investigations currently underway, increasing utilisation of PFDs seems likely as a resource for improvement.

Increased scrutiny

On 1 January 2025, for the first time, the Chief Coroner published what she called a ‘Badge of Dishonour’: a list of organisations and individuals who did not respond to PFD Reports in 2024. These will now be published every 6 months on her website, the last being on 31 December 2025.

Will we see the introduction of an independent body to monitor PFD compliance? The chair of the HSJ’s Patient Safety Watch has referred to this possibly being a reinvigorated National Quality Board.

The MoJ has announced the next official release of Coroners Statistics 2025 for 14 May 2026.

What it means for 2026:

Expect stricter scrutiny of PFD compliance—boards and clinical governance teams need robust response protocols and evidence of change if they are to avoid PFDs and not be ordered to submit additional evidence.

Risk mitigation strategies

• Reduce gaps in risk assessment; care planning; staff competence; post incident records/ quality/ competence/ training; policy compliance.
• Medication management and GP communication: Record continuity; chart accuracy.
• Claims protocols for inquests could reduce risk of PFDs and subsequent satellite litigation.

2)   How will practical application of the Public Office (Accountability) Bill (“Hillsborough Law”) at inquests work?

This had its first reading on 16 September 2025 and its Remaining Stages will begin on 14 January 2026. Key points in the Bill in so far as it relates to inquests include a new statutory duty of candour and assistance, at inquests, inquiries and other investigations; and non-means tested legal aid for advice and advocacy has been extended to the bereaved family at every inquest where a public authority (e.g. an NHS body) is an Interested Person.  

What it means for 2026: It is currently unclear how the expansion of non-means test legal aid will operate; it may cause delays and cost limits will presumably be imposed. Will we see clarification of how this works in practice during 2026?

3)   Continued development & clarity of Coronial system & procedural expectations 

Due to the combined effects of:

a) The 2025 Chief Coroner “Bench Guidance” (published Jan 1, 2025) is a live document that is actively updated. It consolidates and supersedes multiple Guidance Notes and Law Sheets.

b) Death certification reforms and the statutory Medical Examiner system began phasing in from September 2024 and now shape coronial caseload. The ME system requires independent scrutiny of every death—either by a medical examiner or a Coroner. Sector briefings note early impacts: fewer “natural causes” conclusions and a reduction in deaths reported to coroners, consistent with the 2024 data.

c) The Chief Coroner’s Annual Report (2024). Laid before Parliament in September 2025, this sets out work on consistency, training and stakeholder engagement, with recommendations to improve standardisation of services; recruitment notices and society announcements indicate ongoing capacity work.

What it means for 2026

Persistent focus on timeliness and consistency—expect continued training, guidance refreshes and local resourcing debates, with statistics and dashboards supporting performance oversight. Expect sustained effects on what reaches inquest, the mix of conclusions, and interactions between ME reviews and Coronial investigations. Clearer procedural expectations and more consistency nationwide; Coroners and practitioners will be held to Bench Guidance standards in directions, language and participation.

4)   Practical application of the Article 2 arguability threshold and causation test

The new Chapter 20 of the Chief Coroner’s Bench Guidance brings helpful and practical guidance on the application of Article 2 to inquests: clarification on the fact that, for example, all that needs to be demonstrated is an arguable breach of the state’s Article 2 duties – the Coroner never has to determine whether or not an Article 2 duty has actually been breached.

R (Ferguson) v HMAC for Sefton, Knowsley & St Helens [2025] EWHC 1901 (Admin) establishes the principle that the standard for establishing the existence of an Article 2 duty is whether it was arguably engaged on the facts of a particular case, the “arguability” threshold applying to both duty and breach. Also, that causation in an Article 2 contexts requires assessing loss of a substantial chance of survival.

What it means for 2026

The authority in R v HMAC is likely to assist those arguing that an operational duty should be found to have been owed to the deceased on the facts of their particular case, but its wider significance remains to be seen.

Risk management strategies:

• Article 2 arguability can be met where there is a credible suggestion that a service provider knew/ought to have known of a real and immediate risk—raising expectations of proactive risk documentation, care planning and communication
• Refresh Article 2 decision logs and rationale at pre‑inquest stage; explicitly record how you identified/mitigated real and immediate risks in the timeline of care
• Set Art. 2 decision trees for insureds to reduce satellite litigation risk.

5)   Tighter case management on scope of inquests

O’Brien v HM Assistant Coroner for Sefton, Knowsley & St Helens [2025] EWHC 362 (Admin) reinforces that scope turns on actual and material contribution to death (“coronial causation”) and guards against speculative chains.

What it means for 2026: Expect tighter case management—requests to widen scope must clear the “material contribution” test; coroners will rely on Bench Guidance and recent case law to resist speculation.