Coroners are increasingly pointing to the housing crisis in their reports – but can it save lives?

Official coroners’ reports are increasingly warning that the housing crisis and homelessness are leading to preventable deaths, a new report has found.

University of Bristol research analysed prevention of future deaths (PFD) reports related to deaths of homeless or precariously housed people and found increased mentions of housing issues, such as a lack of social housing and the ‘bedroom tax’.

Academics found 18 such cases between 2017 and 2021 but this number has since rocketed to 38 over a much shorter period from 2023 to 2025.

Report author Dr Edward Kirton-Darling, senior lecturer in law at the University of Bristol, said: “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 report showed that coroners are sending the PFD reports to bodies responsible for housing, such as the Ministry of Housing, Communities and Local Government, at a rate of one report every eight weeks – up from one a year compared to the earlier studied period.

The report also calls for improvements to the investigation system at central government, chief coroner and individual coroner level.

That came after researchers dug into coroners’ warnings after more than 33 harrowing deaths across England and Wales.

One case saw a coroner raise concerns over the state of social housing where a man was living after being given a terminal cancer diagnosis. His housing impacted his mental health and he struggled with the digital application process for a new home.

The inquest into his death heard there was a waiting list of 17,000 households for a new home.

Another case heard how one coroner sent five different PFD reports following the death of a man in Cornwall whose mental health deteriorated while waiting for a council home.

The report also highlighted concerns following the deaths of people released into homelessness from prison or living in unregulated accommodation for care leavers. 

“There’s a 200-year history of coroners having responsibilities in relation to social welfare and thinking about housing conditions,” Dr Kirton-Darling told Big Issue. “I wanted to look at the question of how much they’re thinking about that in the contemporary context, particularly thinking about the extensions of inquests because of human rights law.

“Many more coroners were not just thinking about homelessness as something peripheral, but were actually engaging with concerns about homelessness. I thought that that was quite a significant change and something that was worth digging into.

“I was driven by wanting to try and prevent future deaths and think about how we can make it so that if someone does die then lessons can be learned to save future lives. That’s what the system’s supposed to do.”

Dr Kirton-Darling also found a regional disparity across England.

Three cities – Brighton, Manchester and London – were responsible for 58% of the PFD reports. When compared with the Museum of Homelessness’ Dying Homeless Project count, the three cities amount to 37% of people who died while homeless in England in 2024.

Meanwhile, there were no reports issued from cities such as Bristol, Southampton, Nottingham and Exeter, for example, despite numerous deaths of people experiencing homelessness, Dr Kirton-Darling found.

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.”

Read more:

• The number of homeless deaths is an entirely preventable tragedy. What are we doing?
• ‘Shocking’ number of homeless deaths in Scotland spark calls for action ahead of Holyrood elections
• Why we come together to grieve people who died while homeless

Dr Kirton-Darling told Big Issue that guidance from the chief coroner and training on homelessness and housing law for coroners’ offices could help to improve learnings that could prevent future deaths.

With record numbers of people experiencing homelessness and evidence of increasing homeless deaths, the University of Bristol lecturer said the research shows the need for swift action.

“It couldn’t be more urgent,” said Dr Kirton-Darling. “Even if you take just the rough sleeping count, which we know is really problematic, we know that numbers are going up dramatically. We know that there are many overcrowded homes. We know there’s lots more people in temporary accommodation. It’s been a crisis for a long time. It’s becoming an urgently growing crisis. We know full well that poor conditions and a lack of housing contributes to fatality.

“This is the system which is supposed to identify concerns which could prevent future deaths. And so this is the system which ought to be flagging those concerns and there ought to be a system that is able to collate those concerns and be as effective as possible in ensuring that there aren’t rising numbers of deaths.”

Read more about the University of Bristol project here.

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