other resources

The safety of women and babies is at the heart of maternity care. This section aims to provide members with information and resources on improving safety, including alerts issued by NHS England and the devolved nations and learning lessons from incidents, such as prevention of future deaths reports from the judiciary. 

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.

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.

Jennifer Cahill and Agnes Cahill: Prevention of future deaths report

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