Personal Injury, Serious Injury & Clinical Negligence

Impact of Coroner’s Recommendations

Rule 43 letters from Coroners

In our previous blog on the topic Update on Coroner’s Recommendations we highlighted the upward trend of Coroners making recommendations after inquests to try and improve patient safety within hospitals.

Coroner’s recommendations to change working practices take the form of a “Rule 43” letter. Such letters are written by Coroners and sent to various bodies, highlighting any areas where standards could be improved and hopefully prevent similar deaths from occurring in future.

The Ministry of Justice’s eighth report into the matter confirms that a total of 234 ‘Rule 43’ letters were issued by Coroners between 1 April and 30 September 2012. Of this sum, 102 reports related to hospital deaths, which is an overwhelming majority. Other organisations who received Rule 43 letters include Government departments, local authorities, regulatory bodies and trade associations, police and emergency services, prisons, and nursing/care homes.

The established trend highlights continued failings within the NHS in relation to note-taking, staffing, training, communication and record-keeping. Reports reveal lack of procedures and protocols (or a failure to follow them) as major concerns. Coroners are repeatedly asking hospitals and other organisations to learn lessons and make sure that changes are implemented properly.

In its most recent report, the MoJ also identified issues of failed communication between agencies and departments within hospitals, particularly in the context of mental health-related deaths. Rule 43 letters in 2012 have emphasised that staff caring for patients at risk of self-harm required better training.

The majority of responses to Rule 43 letters have been positive, and confirm that hospitals are taking Coroners’ concerns seriously. Organisations are now taking proper steps to ensure that training and/or guidance is updated to hopefully improve patient safety and reduce the number of deaths in future.