Coroner's Report to Prevent Future Deaths

Regulation 28 Coroners (Inquests) Regulations 2013

The avoidance of future deaths has always been at the core of the role of the coronial system.

A Coroner has the power to make a report to prevent future deaths which is provided under regulation 28 Coroners (Inquests) Regulations 2013. Hence it is often referred to as a Regulation 28 report. The aim of such a report is to improve public health and safety.

Not only does a Coroner have the power to make a report but in fact they have a legal duty to do so in certain circumstances. The circumstances are set out in Paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009:


(a) a senior coroner has been conducting an investigation under this Part into a person’s death,

(b) anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and

(c) in the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances, the coroner must report the matter to a person who the coroner believes may have power to take such action.

The legislation also imposes a legal duty on anyone to whom a report is made to respond to it within 56 days, where an explanation is required as to what the receiver of the report proposes to do and how long they anticipate it will take. If they do not propose to take any action then they must explain why. The report and the responses will be shared with those who were interested parties at the inquest. A copy of the original report and the response must then be provided to the Chief Coroner. Many of these reports are published publically. If there are areas of concern the Chief Coroner may choose to take these issues further.

Such reports can be made for a wide variety of reasons from ambulance delays to public highway infrastructure issues. Very often the issues which are highlighted during the investigation stage of an inquest are rectified prior to the final inquest hearing in which case if the Coroner is satisfied that the issues has been resolved sufficient they need not make a report.

In some cases the report that is made may not even relate directly to the death that is being investigated by the Coroner, it could simply be a separate issue that came to light during the Coroner’s investigation.

It is however important to understand that the Coroner has no power to make recommendations as to what action should be taken, but to simply highlight the fact that if the issues is not addressed this could result in future deaths.

In recent news, Betsi Cadwaladr University Health Board and the Welsh Ambulance Service have received a Prevention of Future Deaths notice following the death of 93-year-old patient; read more on this story here.

Sometimes the making of a report may provide comfort to a bereaved family and therefore it can be important to be legally represented at an inquest to ensure that any concerns can be appropriately addressed to the Coroner.

If you require further information regarding this article or require advice in relation to Inquest proceedings please contact Ian Barnes on 01978 291000 or [email protected]