Personal Injury, Serious Injury & Clinical Negligence

Update on Coroner’s recommendations

Following the implementation of The Coroners (Amendment) Rules 2008, the remit of Rule 43 enables Coroners to make recommendations to hopefully prevent future deaths. Copies of such reports are provided to any interest persons and to the Lord Chancellor.

The 2008 Rules introduced a new statutory obligation for organisations to respond to Rule 43 reports within 8 weeks of receipt. The response must provide details of any actions which have been (or will be) taken, or provide an explanation when no action is deemed necessary or appropriate.

The Ministry of Justice have recently released their latest report on the summary of Rule 43 reports issued by Coroners in England & Wales between 1 October 2011 and 31 March 2012.

Throughout the relevant period, a total of 233 reports were issued under Rule 43, which include lessons learned from 242 inquests. This is the highest number of reports issued in any six month period since the Ministry of Justice began reporting in July 2008.

Over a third of reports issued in this period relate to deaths in hospitals, which are by far the most common reason for inquests being held. The second most common reports related to road traffic deaths, and the third related to mental health related deaths. This is the first occasion when mental health related deaths have been in the top three categories.

Rules 43 reports relating to hospital management of patients have consistently been on the increase since the changes were implemented in July 2008. The reports frequently identify concerns over hospital policies and practices, particularly in relation to poor note-taking, staffing levels, training, communication and handover, and the recording of medications.

Coroners have reported to the Department of Health on occasions where they have identified concerns which may have national implications, or if they feel such information could be usefully disseminated to all NHS Trusts.

On the whole, the statistics are encouraging and show that Coroners are taking a more active role in highlighting failings within the NHS, and particularly to ensure valuable lessons are learned by those providing medical care and assistance.

If you have concerns relating to a possible medical negligence matter please contact the team.