The number of coroners’ reports warning that action could be taken to prevent future deaths of people experiencing homelessness has surged by more than 250% in recent years, according to new research from the University of Bristol.
The study, led by Dr Ed Kirton-Darling, Senior Lecturer in Law at the University of Bristol, analysed Prevention of Future Deaths reports (PFDs), the formal notices issued by coroners when an investigation reveals circumstances that could lead to other deaths, and found a dramatic increase in those relating to people who were homeless or precariously housed.
Between 2017 and 2021, coroners issued an average of 3.6 such reports each year. Between 2023 and 2025, that figure rose to 12.7 per year, an increase of 252%. Over the same period, the total number of PFDs issued across all causes rose by a much lower 46%.
Perhaps more significantly, the research found a marked shift in who coroners are addressing. In the earlier period, all housing-related reports were sent to local or regional government. In the past three years, coroners sent reports to central government on eight occasions, alongside 15 different local authorities and five third-sector organisations.
The reports themselves highlight systemic issues including the impact of the ‘bedroom tax,’ the chronic shortage of social housing, inadequate facilities for people with mental health needs and failures in accommodating those with intersecting vulnerabilities such as young LGBTQ+ people and care leavers.
One coroner, writing about a man who died after struggling to manage rent arrears linked to the bedroom tax, addressed their concerns directly to the Ministry of Housing, Communities and Local Government. Another highlighted the case of a family forced to live apart for three months due to a shortage of public housing, describing the situation as having a ‘significant impact’ on the father’s mental health.
Dr Kirton-Darling said: ‘This research is the first to look at how Coroners – who have to investigate these cases – report on issues connected to homelessness and precarious housing to prevent future death.
‘The results are quite startling. In the earlier data set, when the person who died was experiencing homelessness, this was often only mentioned in passing, while more recent reports show many more Coroners are actively focusing on this.’
The research also reveals striking geographical variations, as Dr Kirton-Darling points out: ‘Despite numerous deaths of homeless people in cities like Bristol, Southampton, Nottingham and Exeter, there were no reports by Coroners. There were none from the East Midlands as a region, or from South East England, except for Brighton.
‘By contrast, three cities – namely Brighton, Manchester and London – produced the majority (58%) of the reports. This can be set against research by the Museum of Homelessness, which counts the deaths of people experiencing homelessness and shows that these three cities amount to 37% of the number of people who died while homelessness in England in 2024. Clearly, some Coroners could do more to ensure they identify issues connected to homelessness in their investigations.
The report makes a series of recommendations, including that the Chief Coroner introduce a ‘homelessness’ tag on the PFD database to improve tracking, and provide specific training for coroners on housing and homelessness law and policy.
It also urges central government to implement a long-called-for National Oversight Mechanism to scrutinise responses to PFDs, and to ensure that deaths of people experiencing homelessness are given specific focus.
Ciara Bartlam, a barrister and former specialist homeless officer, said: ‘Having worked in homelessness and now as a barrister representing bereaved families at inquests and inquiries, I can see the urgent need for action that this report makes the case for so succinctly.
‘This research very clearly shows that the system must start to learn from the deaths of people experiencing homelessness – which requires data, training for coroners and a national oversight mechanism that is long overdue. This is a vital piece of work, and it is just the start.’
The full research can be read here.
Photo: Jon Tyson
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