The Coroner Role & Preparing for A Coroner's Inquest

“Coroners’ expectations can influence an organisation’s choice of learning response to an incident.”

Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development, HSSIB, October 2025

“Attending a Coroner’s court to give evidence can be worrying if this is something you have never done before, or if you have previously had a challenging experience”

“There were 147,800 deaths reported to coroners in 2025, the lowest level since the start of the annual time series in 1995… As a proportion of deaths reported, the number of inquests opened is at its highest level since the start of the annual time series in 1995, at 24%.”Coroners Statistics 2025, Ministry ”

This virtual conference focuses on the role of the Coroner, the coronial investigation and inquest process, and preparing effectively for a Coroner’s Inquest. The conference will provide an important update on current developments in the coroner system, including the impact of the statutory Medical Examiner system and Death Certification Reforms on referrals, investigations and learning from deaths.

The conference will explore the Coroner’s investigation from notification and referral through to the inquest, preparing witness statements and giving evidence, supporting staff involved in proceedings, and understanding what families want and need from the process. Practical sessions will provide an opportunity to understand how an inquest works in practice and develop confidence in preparing for and attending Coroner’s Court.