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Chief Coroner’s 10th Annual Report to the Lord Chancellor

Volume 749: debated on Wednesday 8 May 2024

I am pleased to lay and publish the Chief Coroner’s tenth annual report to the Lord Chancellor on the operation of coroner services, under section 36 of the Coroners and Justice Act 2009.

The report provides a comprehensive overview of all the work taken forward across the coroner service in England and Wales in the calendar year 2023, under the leadership of the Chief Coroner. It provides valuable insights into the service’s operations and future direction.

In particular, the Chief Coroner’s report sets out:

An overview of the work that he, as well as coroners, their officers and their staff have undertaken in 2023;

Statistics for 2023, with particular focus on cases over 12 months old, service deaths and PFD—prevention of future deaths—reports;

The training courses and updated guidance that coroners and their officers have received, and engagement with a wide range of stakeholders; and

Recommendations on changes to improve coroner services further.

The report also includes the Chief Coroner’s 10 years post-reform review of the coroner service, which was published in January 2024.

I am very grateful to His Honour Judge Thomas Teague KC for his work during the course of 2023 in guiding and supporting coroners. As he prepares to retire in May, I also extend my heartfelt appreciation for his dedication and leadership since his appointment in December 2020, particularly in navigating the complexities of the pandemic and in ensuring the post-pandemic recovery of the coroner system. His contribution has been invaluable, and I thank him for his unwavering commitment to the service.

I am grateful, too, to all coroners and their officers and other staff, for supporting the Chief Coroner and HM Government in improving services for the bereaved, and for their unwavering commitment and dedication to the crucial work which they undertake.

The report will be laid in Parliament and will be available online at