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It’s all in the numbers – the headlines from the latest published Coroner’s statistics of 2021:


My last foray into numbers resulted in my then maths teacher gifting me one of the ‘inspirational quote” posters that lined the classroom. It read “boredom is simply the lack of imagination”. With that in mind, the latest statistics provide some matters worthy of comment and, whilst it may not pique the same level of interest that Richard Jolly may garner (if you know then you know), this article gives you the headline news.

The covid-19 caveat:

Much like other areas of the legal profession, inquests have felt the impact of covid-19 in numerous ways. In most Coronial regions the pandemic created/exacerbated a backlog for inquests. This was largely caused by practical issues as most Coroner’s courts were unable to facilitate the requirements on social distancing and, therefore, deal with the often larger and more complex jury inquests.

It is not, therefore, surprising that jury inquests rose by 79% from 2020 to 2021; and that there was a rise in the number of suicide conclusions returned in 2021. It is, perhaps, fair to say this is an instance where correlation and causation are more firmly aligned.

Deaths in state detention:

Deaths in state detention reported to Coroner’s increased by 3% in 2021, reflecting a rise in the number of deaths in prison custody. Whilst deaths in state detention cover an umbrella of detention scenarios (individuals subject to Mental Health Act detention, prison custody and police custody etc) there was a marked rise by 55 deaths in prison custody cases.

The explanation for this is not readily apparent, however it may be that reference to the pandemic is of assistance. Firstly, prisons were not immune from the deadly effects of covid-19 and the figures may be reflective of a delayed, yet significant, impact made the virus. This seems to be the clearest explanation: the Safety in custody statistics note that there were 65 suspected covid-19 deaths in the quarter from January – March 2021. Indeed, there has been a marked decrease in the number of deaths in prison custody from March 2020 – 2021 (407 deaths); and March 2021 – 2022 (287 deaths).

Secondly, and likely to a more limited extent, during the pandemic prisons entered a significantly restricted lockdown regime which continues to different degrees in some prisons. This had an impact upon the availability of drugs entering prisons. It may be, therefore, that the increase noted partially reflects a rise in drug related deaths as restrictions lifted and/or innovative ways have been found to circumvent the restrictions and get drugs into prison. However, this is not based on any empirical evidence and is merely supposition.

It is, however, pertinent to note that the Safety in custody statistics also shall that whilst the number of self-inflicted deaths fell, when we consider this in conjunction with the prison population, the rate of self-inflicted deaths has in fact remained unchanged from the previous year at 1.0 person per 1,000.

There was also a significant rise in the number of police custody deaths, from 10 to 18. Whilst this figure represents a minor proportion of the number of deaths in custody it is perhaps concerning that the figure has nearly doubled in the last year.

Number of inquests:

In light of the backlog created by the pandemic it is unsurprising that in 2021 there was a significant rise in the number of inquests opened and the number of jury inquests held. However, the fact that the number of jury inquests held remains substantially lower than 5-year pre-pandemic average indicates that some Coroner’s areas continued to struggle to hold jury inquests following the pandemic.

PFD reports:

There were 440 PFD reports issued in 2021, the region which issued the greatest number of PFD reports was the North West (86) – Manchester South was the area which issued the most within this region (45).  The area that issued the most PFD repots was South Northumberland (50). Focusing on Yorkshire and the Humber, the most PFD reports were issued by the West Yorkshire (Eastern) region (25). No empirical study has been conducted on the breakdown of these reports but the published statistics notes that the categories focused on healthcare related issues (both inside and outside of the community).


For a more comprehensive and deeper dive into the published statistics the reader is directed to the link above and the data tables which can be accessed online.


Nathan Davis

Nathan has a burgeoning inquest practice and has experience in both jury and article 2 inquests. He is available to represent a range of interested parties from bereaved families, public and private bodies and other interested persons.

Contact Nathan’s clerks

Madeleine Gray on 0113 202 8603

Patrick Urbina on 0113 213 5250