Birmingham's coroner vowed to bring Government agencies and lawyers into line, after he revealed yesterday's inquest took 16 months to reach court.
Aidan Cotter spoke out after a jury returned their verdict on George Inwood - a case Mr Cotter claimed should have been heard within six months.
He told all representatives that they should be prepared for inquests "much, much earlier" from now on.
Mr Cotter said: "It has taken 16 months to reach this stage and I think the family would much have preferred to hear this six months after Mr Inwood's death, not 16 months later.
"I'll bet they've not had the chance to start the grieving process yet because they've only just heard what happened."
He added: "How many other deaths might have occurred? What's the point of finding out 16 months too late a lesson that could have saved lives?
"I am telling you all it's going to change. You are all going to appear at inquests much, much earlier.
"This inquest should have been heard in 12 months, it could have been held in nine months, but in future I'd like it to be heard within six months."
The coroner continued to vent his opinion, telling the packed court room it was a legal requirement to hold an inquest as soon as possible after a death.
Mr Cotter said: "For some considerable time I've been dealing with various agencies and advocates for families, trusts and companies, and you've all got to change your way of thinking.
"You have to accept that inquests should be held as soon after the death as is practicable.
"It's not just me saying that, it's what the law says under section 8 of the Coroners' Act 1988."
He criticised an emerging culture within legal practices and Government offices to prolong the inquest process.
"A custom has been built up that agencies don't submit their reports to me until they've dotted every 'i' and crossed every 't' and sent it to everybody in the organisation with an interest in it," said Mr Cotter.
"Solicitors then expect to see every piece of paper that has been generated and have time to pore over them before deciding how best to proceed.
"As a result inquests like this can take 16 months to be heard.
"However, I am aware that there are other organisations, such as the Prison Service, where that can take three years.
"I am determined that in Birmingham and Solihull this is going to stop."