Lancashire Inquests, Extents, And Feudal Aids: 1310-1333...

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As of 3 April 2017, a person subject to DoLS is no longer considered to be ‘otherwise in state detention’ for the purposes of the 2009 Act and therefore, any deaths on or after this date are no longer required to be reported to the coroner. The statistics reported in 2018 therefore no longer include DoLS cases. This change has reduced the number of deaths in state detention reported within the 2018 bulletin and had a corresponding effect on other statistics, for example inquests opened and inquest conclusions, in particular deaths by natural causes and the average time taken to complete an inquest. 4. Data Quality and Sources

The profile of the age of deceased at inquests has changed slightly from 2020 to 2021. The percentage of inquests completed relating to persons aged 65 or over has decreased by two percentage points from 55% to 53%. By contrast, 5% and 41% of inquests concluded related to persons under 25 years and those between 25 and 65 years of age respectively, both up one percentage point compared to 2020 (see Table 8). Any object at least 200 years old which the Secretary of State considers to be of outstanding historical, archaeological or cultural importance. COVID-19 deaths are likely to be considered to be deaths from natural illness, and therefore will not of themselves be reported to coroners, apart from deaths which the coroner is under a statutory duty to investigate and hold an inquest (essentially deaths in custody or other forms of state detention). Inquests are usually opened in less than 20% of all deaths reported to coroners. In such cases, Coroners are required to provide us with the conclusions of these inquests. The list of short form inquest conclusions which the coroners can provide is set out in legislation and can be found in Table 7 of the coroners’ publication. 1.3 Summary of relevant Policy Changes due to Covid-19 [footnote 1]This conclusion may be recorded, for example, due to termination of a pregnancy, lawful shooting by a police officer, or a death resulting from self-defence. Narrative conclusion Look in KB 10 for any inquests which may be found among the London and Middlesex indictments. Coroners’ records from other courts (1339–1896) Inquest conclusions up 4%, the largest rise seen in accident/misadventure, suicide and unclassified conclusions The coroner has however indicated that he is going to make a Prevention of Future Deaths report to the Minister for Care and Mental Health at the Department of Health and Social Care. This will highlight his concern that Children’s Social Care do not automatically continue their involvement in a child or young person’s care while they are an inpatient.

A coroner’s inquest is held for all deaths in custody or state detention. An inquest with a jury is held where the deceased died while in custody or state detention and the death was violent or unnatural, or of unknown cause; where the death resulted from an act or omission of a police officer or member of a service police force in the purported execution of their duties; or where the death was caused by an accident, poisoning or disease which must be reported to a government department or inspector. Jury inquests are not required where the deceased died in custody or state detention but from natural causes.Those which resulted in verdicts of murder or manslaughter (including many that would now be regarded as misadventure) are normally found in the indictments or depositions files of the relevant circuit. There were 32,762 inquests opened in 2021, a 2% increase on 2020. The number of inquests opened in 2018 and 2019 were mostly consistent with figures before DoLS investigation requirements (see section 4) were introduced (excluding 2014, which had 25,889). However, 2020 saw an increase to 31,991 and 2021 had the highest number of inquests opened since 1995, excluding the years when DoLS investigations were required. The percentage of all registered deaths that were reported to coroners has remained largely stable (a less than one percentage point decrease) when compared to 2020, and is the lowest level since 1995. Once that MCCD reaches the registrar there are two possibilities depending on whether the deceased was seen before or after death. If a medical practitioner (who does not have to be the same medical practitioner who signed the MCCD) attended the deceased within 28 days before death (a new, longer timescale) or after death, then the registrar can register the death in the normal way. Second, if there was no attendance either within 28 days before death or after death, then the registrar would need to refer that to the coroner. Medical practitioners’ duty to notify coroners

The coroner found that there was no risk assessment in place at Marshall’s discharge and that the referral to Children’s Social Care did not happen for another three months. The coroner described evidence about the discharge from Marshall’s Care Coordinator as ‘unimpressive’ and found that the referral should have taken place much earlier.The evidence highlighted that the issues in Marshall’s case lie in the interface between mental health services and Children’s Social Care. Those involved in these agencies showed confusion and uncertainty about their responsibilities in this area when giving evidence to the inquest, particularly witnesses from the Trust.

In 2021, the number of unclassified conclusions increased by 1,572 cases (up 24%) to 8,125. Unclassified conclusions made up 25% of all inquest conclusions in 2021, an increase in proportion by four percentage points compared to the 2020 amount. The rise in unclassified conclusions seen until 2014 and again from 2016 is partly due to the increasing use of what are known as ‘narrative conclusions’ by some coroners. In these cases, the conclusion is recorded as unclassified. As well as narrative conclusions, this category includes short non-standard conclusions which a coroner or jury might return when the circumstances do not easily fit any of the standard conclusions [footnote 9]. Within the ‘Key Findings’ sections, figures greater than 1,000 are rounded to the nearest 100. The following symbols have been used throughout the tables in this bulletin: The remainder was forwarded to the King’s Bench. As London and Middlesex were anomalous jurisdictions without assize courts, their inquisitions were not treated in the same way. https://www.judiciary.uk/related-offices-and-bodies/office-chief-coroner/ 2.2 Chief Coroner’s annual reportA conclusion consists of the ‘determination’, which states who died, and where, when and how they died; and ‘findings’ which allow the cause of death to be registered. The coroner or jury may use one of the following short form conclusions [footnote 7]: The proportion of conclusions recorded as suicide has remained broadly constant over the past four years, seeing an increase from 14% of all conclusions in 2020 to 15% in 2021. Pressure on NHS front line services has meant that clinicians have not always been available to attend inquests, causing delays, although many have attended remotely, a trend which is likely to continue after the pandemic. ONS registered deaths fell by 4% [footnote 2] from 2020 to 2021. In comparison, the number of deaths reported to coroners decreased by 10,258 (5%) to 195,180, the lowest level since 1995. The proportion of registered deaths in 2021 that were reported to coroners was 33%, down less than one percentage point from 2020.