How well do Regulation 28 reports serve future public health and safety?

Abstract

Her Majesty’s (H.M.) coroners issue Regulation 28 (Reg. 28) reports following inquests. These reports concern hazards which, if mitigated, might prevent future deaths, and have addressees who are best placed to take remedial actions. Since 2013, the reports and addressees’ responses are copied to, and electronically published by, the Chief Coroner in non-exclusive demographic, aetiological or venue categories. Three of those categories were chosen so as to minimise the replication of unique cases – child deaths; alcohol, drugs and medications (ADM); and railways – with the most recent 50 reports in each category. A further ad hoc sample of neonates was taken after a finding in the first of these. The principal findings are: (a) H.M. coroners generate Reg. 28 reports at different rates (including 27 coroner areas with none at all; random variation probability p ≈ 10–6); (b) there is a large deficit of addressees’ responses compared with Reg. 28 reports that are issued; (c) addressees from large organisations are more likely to respond than small ones; (d) substantive remedial actions appear in only a further subset of addressees’ responses; and (e) there is a sex imbalance in Reg. 28 reports which is least explicable for neonates. It is concluded that the Reg. 28 report system is haphazard in many ways. As the only official publication from H.M. coroners’ courts, Reg. 28 reports have a large scope for improvement, which might promote support from bereaved families and the wider public for the process of inquest. Suggestions for process improvement are made.

Deaths from cardiovascular disease involving anticoagulants: a systematic synthesis of coroners’ case reports

“… 24 This questions whether PFDs are fulfilling their purpose. Similar to Fox and Jacobson, 25 the present study found pronounced geographical variation in the issuing of PFDs and poor response rates. A review of the coronial system in England and Wales highlighted a lack of accountability, leadership, and quality assurance.…”

“…Our study builds on prior research that evaluated smaller samples of coroners' reports (15,16,(25)(26)(27). Compared with previous studies (26,28), we did not identify a sex imbalance.…”

“…Our study builds on prior research that evaluated smaller samples of coroners' reports (15,16,(25)(26)(27). Compared with previous studies (26,28), we did not identify a sex imbalance. However, we found that new hazards were rarely identified and that most PFDs were addressed locally, as shown by Ferner et al (15), which means that valuable lessons were not widely disseminated and may be why we found that coroners repeatedly expressed similar concerns, in line with former research (25).…”

Deaths from cardiovascular disease involving anticoagulants: a systematic synthesis of coroners’ case reports

“…This questions whether PFDs are fulfilling their purpose. Similar to Fox and Jacobson [26], we found pronounced geographical variation in the issuing of PFDs and poor response rates. A review of the coronial system in England and Wales highlighted lack of accountability, leadership, and quality assurance [29].…”

Preventable deaths involving medicines in England and Wales, 2013-22: a systematic case series of coroners’ reports

“…Despite the legal requirement to respond to PFDs, there is no process for enforcing and auditing responses to ensure that necessary actions are being taken to prevent similar deaths. Others have suggested the need for sanctions to improve response rates and enforce Regulation 29 of The Coroners (Investigations) Regulations 2013 (9,37). But whether such sanctions would lead to increased actions for reducing preventable deaths has not been tested.…”