Failing the dead: How medical ignorance is killing Britain’s coroner service (21 June 2025)

Summary

Grieving families are being left without answers due to an overstretched, untrained coroner's service that is "not fit for purpose".

In Cornwall, 54-year-old Charles Devos died from a bowel infarction in January 2021 after waiting several hours for an ambulance. The coroner court refused to open an inquest for over a year, despite repeated submissions there was reason to suspect the death was “unnatural.”  

Four years later, a Judiciary Prevention of Future Deaths Report eventually stated: “If an emergency ambulance had collected Charles in the early hours of 9 Jan it is probable he would have received lifesaving treatment.” 

A coroner is a judge whose job is to investigate unnatural or violent deaths, to find out who died, how, when, and where. They should, in the words of former Chief Coroner Thomas Teague KC, “provide bereaved families with answers.” However, too often, key details are being missed or omitted from coroners’ records – meaning families are left without answers, and the possibility to prevent future deaths is being missed.