Local variations in reporting deaths to the coroner in England and Wales: a postcode lottery?

Aims In England and Wales, doctors are charged with a responsibility either to report a death to the coroner or issue a medical certificate specifying cause of death. A lack of formal prescriptive or presumptive oversight has resulted in the promulgation by individual coroners of local reporting regimes. The study reported here identified overall and gendered variations in local reporting rates to coroners across the jurisdictions of England and Wales, consistent over time.

Methods Analysis was performed on Ministry of Justice (MOJ) data pertaining to the numbers and proportions of deaths reported to the coroner by jurisdiction over a 10-year period (2001–2010). Office of National Statistics (ONS) data provided the numbers of deaths registered in England and Wales over the same period to serve as a denominator for the calculation of proportions. Where coroner jurisdictions (and local authorities) had been amalgamated during this period, the combined reported and registered death figures have been included in line with the current jurisdiction areas.

Results While reporting rates for individual jurisdictions were found to be stable over the 10-year period, wide local variations in reporting deaths to coroners were found with no obvious demographic explanation. The gender of the deceased was identified as a major factor in local variation.

Conclusions The decision to report a death to the coroner varies across jurisdictions. Implications for coronial investigations are discussed and the need for wider research into coroners’ decision-making is proposed.