What Does A Coroner Do at an Inquest?

An inquest is a judicial inquiry conducted by a coroner to determine the circumstances surrounding a death. The coroner’s primary duty is to investigate deaths that are violent, unnatural, or occur in custody or under unknown circumstances. While an inquest cannot assign blame or liability, it seeks to establish key facts about how the death occurred, and in some cases, identify ways to prevent similar deaths in the future. For further reading please click on this link: What Happens at an Inquest Hearing

Coroners play a critical role in public safety by issuing Prevention of Future Deaths (PFD) reports when they identify risks that could lead to further fatalities. However, the failure to act on these reports has been linked to thousands of preventable deaths annually.

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What is a Prevention of Future Deaths Report?

A PFD report is issued when a coroner identifies risks that pose a threat to life. Public bodies such as government departments, NHS trusts, or prisons are required to respond in writing, detailing how they plan to address the risks. Unfortunately, there is no legal requirement to act on these concerns, and many recommendations are ignored.

For example, despite coroners highlighting issues such as unsafe drug labelling or inadequate care provision in PFD reports, little action is often taken. This inaction has resulted in recurring fatalities and missed opportunities to save lives.  A database to track Preventable Deaths can be found on this tracker: Preventable Death Tracker.

The Reality: Inaction and Lack of Accountability

Since 2013, over 5,400 PFD reports have been published, yet analysis reveals serious shortcomings:

•28% of reports have received no responses.

•14% of responses were incomplete or insufficient.

•Many coroners issue no PFD reports at all, while a small percentage of coroners are responsible for most of the reports filed.

The lack of a central system to monitor responses or enforce recommendations undermines the preventative potential of inquests. As one coroner put it, “I write a lot of these reports, and often nothing happens.”

High-Profile Examples of Ignored Warnings

The consequences of ignoring coroners’ advice are devastating:

•Concerns over the prescription and labelling of SSRI antidepressants have been repeatedly raised, but no meaningful action has been taken.

•A deadly poison linked to suicides has remained available for years despite repeated PFD reports calling for its restriction.

•Failures in record-keeping, staff training, and care provision continue to contribute to avoidable deaths.

These failures highlight the urgent need for systemic reform to ensure that PFD reports lead to real change.

Calls for Reform: The Need for a National Coroner Service

Experts, including former Chief Coroner Peter Thornton KC, have called for the creation of a national coroner service to improve accountability and consistency in handling inquests. Thornton outlined key issues:

1.Not enough coroners issue PFD reports.

2.Coroners lack the authority to enforce action on their recommendations.

3.There is no national oversight or follow-up system to track progress.

Without systemic reform, the same failures will continue to cost lives unnecessarily.

How Fatal Accidents Legal Support Can Help

If you have lost a loved one due to preventable circumstances and believe that failings highlighted during an inquest were ignored, you may have grounds for legal action.

Our resources provide information on:

•The coroner’s role in investigating deaths.

•What to expect during an inquest.

•Your rights as a bereaved family member.

•How to address preventable deaths through legal channels.

Conclusion: Ensuring Action and Accountability

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The inquest system has immense potential to save lives, but its effectiveness is undermined by inaction and lack of accountability. Coroners must be empowered to ensure their recommendations lead to meaningful change. For families navigating the inquest process or seeking justice for preventable deaths, expert legal advice can make all the difference.

Together, we can advocate for reforms that prioritise life-saving action and hold institutions accountable.