This study explores, analyses and seeks to explain the processes by which legislative changes were achieved to overcome the problems associated with the role and duties of the office of coroner from the mid nineteenth century to the 1920s. From time to time during the period, the office was exposed to political and public scrutiny that brought calls for reform. Despite that, and the general recognition that change was necessary, the process was extremely protracted and reform limited so that when the 1926 Act reached the statute book, it was greeted with a level of subdued dissatisfaction. Throughout the period, the coroners resisted change based on an appeal to their traditional links with the people and representing the office as an ancient institution rooted in long established custom and practice. Despite that, the coroners were unable to evade the impact of changes associated with developments in local and national government which had an indirect, though significant, effect on coroners' reform. For most of the period, the policy of successive governments was to have no policy on coroners. To fill that void,various groups with conflicting interests and ambitions proposed changes to meet their needs and attempted to influence the government to implement them. A slow, complex, haphazard, fragmented and undirected process evolved that had its own dynamic. There was no strategist, no over-riding driving force, no single source. Suggestions were adopted, modified or rejected to produce a 'policy' that was eventually accepted by the Home Office. From the detailed examination of the complex events, issues and stances adopted by the various bodies, including the Home Office, an explanation for the unusual, slow and tortuous process of reform emerges. Coroners' problems were a minor issue for the government and carried little weight in the wider scheme of politics. With such a low priority rating, the government was reluctant to intervene except under the pressure of public criticism when events created a crisis or near crisis. Eventually, a minimum legislative intervention brought closure, but left important problems unresolved. The coroners still investigated unexplained deaths on behalf of the Crown and retained intact their traditional authority, independence, common law powers and discretion.