other resources
Prevention of future deaths report
After an inquest, the Coroner can write a ‘Prevention of Future Death’ or ‘Regulation 28’ report. This happens especially where the Coroner has heard evidence that deaths in the future could be avoided with better preventative action.
Paragraph 7 of Schedule 5, Coroners and Justice Act 2009, provides coroners with the duty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths. They have to respond to these within 56 days showing how they have made changes according to the Coroner’s recommendations, or how they intend to.
All Prevention of Future Death reports and responses are sent to the Chief Coroner and are usually published on the Judiciary website. Where the RCM has responded to a Prevention of Future Death report, these responses appear below when they have been officially published.