Recommendation F45: Use of information about compliance by regulator from: Inquests
From Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, published 6 February 2013.
Recommendation
The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.
In brief (written by this site)
In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England regarded the recommendation as superseded, explaining that a statutory medical examiner system took effect in September 2024 to scrutinise non-coronial healthcare deaths (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team found that the Care Quality Commission and the Coroners’ Society of England and Wales had agreed a Memorandum of Understanding requiring coroners to notify the regulator of inquests involving care concerns (The Thirlwall Inquiry legal team, May 2024).
AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026. The record below is the sources' own words.
Government response
Accept in principle.
Coroners’ investigations and inquests can provide useful information on the quality of services delivered by care providers and any risk of future deaths. As a result, the Care Quality Commission already receives Reports to Prevent Future Deaths and disclosure in inquests where they have interested person status.
Since 25 July, coroners are under a statutory duty to make details of the date, time and place of all inquests available before hearings commence. However, in order to support its new inspection model, the Care Quality Commission may require further details regarding upcoming inquests.
To this end, the Care Quality Commission will undertake an analysis of the information available from coroners’ investigations and inquests, along with other information it already receives relating to expected and unexpected deaths. It will consider the findings of that analysis, including how it could target requests for information from coroners and any burden that collecting this data might impose, working with the Coroners’ Society of England and Wales, the Office of the Chief Coroner, the Ministry of Justice and the Department of Health. Together, they will develop an appropriate way forward.
In addition, the Care Quality Commission is also working with the Coroners’ Society of England and Wales and the Office of the Chief Coroner in establishing a Memorandum of Understanding with the aim of achieving better working relationships and the sharing of information between the Care Quality Commission and coroners.
How this response relates to the recommendation
Site note: This is volume two of "Hard Truths: The Journey to Putting Patients First" (Cm 8777-II), the government's response to the Inquiry's 290 recommendations, published by the Department of Health on GOV.UK on 19 November 2013 and dated to that day here. The PDF the row links to is the accessible edition, whose title page reads "January 2014". The Department of Health has been the Department of Health and Social Care since January 2018. The volume says it includes accounts from each of the national organisations the recommendations name, but it does not mark which passage each organisation wrote, so every row is filed under the Department that published it.
Blanket government agreement does not establish acceptance or delivery by each addressee. Some response passages cover groups of recommendations.
Scope of the government response
Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.
Delivery
DHSC and NHS England state no delivery position (27 February 2026)
This recommendation precedes the Health and Care Act 2022 and Coroners and Justice Act 2009.
A new statutory medical examiner system is being rolled out across England and Wales. The purpose of the medical examiner system is to:
• Provide greater safeguards for the public by ensuring independent scrutiny of all non-coronial deaths • Ensure the appropriate direction of deaths to the coroner
• Provide a better service for the bereaved and an opportunity for the to raise any concerns to a doctor non involved in the care of the deceased
• Improve the quality of death certification
• Improve the quality of mortality data
From 9 September 2024 all deaths in any health setting that are not investigated by a coroner will be reviewed by NHS medical examiners. The changes, which form part of the Department of Health’s Death Certification Reforms, were announced by the government on 15 April 2024, and came into force on 9 September 2024.
Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Superseded”. Table row: section 18.2 No. 45, PDF page 448-449.
Department of Health and Social Care says in progress (11 February 2015)
The Care Quality Commission is undertaking an analysis of the information available from coroners’ investigations and inquests, along with other information it already receives relating to expected and unexpected deaths. It will consider the findings of that analysis, including how it could target requests for information from coroners and any burden that collecting this data might impose, working with the Coroners’ Society of England and Wales, the Office of the Chief Coroner, the Ministry of Justice and the Department of Health.
In addition, the Care Quality Commission is also working with the Coroners’ Society of England and Wales and the Office of the Chief Coroner in establishing a Memorandum of Understanding with the aim of achieving better working relationships and the sharing of information. The Care Quality Commission continues to receive prevention of future death reports, and received 127 notices between August 2013 and August 2014.
The Care Quality Commission now has a single point within the Care Quality Commission where all Regulation 28 notices from Coroners are received. There is a central record to enable tracking of the regulations from receipt through to response and the Care Quality Commission has created detailed guidance on internal processes to facilitate earlier involvement in inquests including the provision of information. In the future there is the potential for a reporting capacity.
Site note: This is the supporting annex published on 11 February 2015 with "Culture change in the NHS: applying the lessons of the Francis Inquiries" (Cm 9009), attached to the GOV.UK page as "Culture change in the NHS supporting annex". The annex has no title page; that title is GOV.UK's and the PDF's own. Its table has four columns (No., Recommendation, Hard Truths Government response, Progress update), and the row carries the Progress update cell. No column says which organisation wrote an update, so the row is filed under the Department of Health (now the Department of Health and Social Care), which published it.
Site note: The Inquiry addressed this recommendation to the Care Quality Commission, not to the Department of Health. The annex gives this update in the Department's publication and does not say who wrote it, so the row is the Department's report of the progress made on it.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry legal team (15 May 2024)
This recommendation was accepted in principle by the Government.
In the January 2014 Hard Truths report, the Government said that the Care Quality Commission was undertaking an analysis of the information available from coroners’ investigations and inquests, with a view to targeting requests for information from coroners.
The Coroners’ Society of England and Wales and the Care Quality Commission entered into a Memorandum of Understanding, whereby they agreed coroner should notify the Care Quality Commission as soon as is reasonably practicable of any inquest where concerns exist about the care or treatment received by a deceased.
Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review colours its Extent of Implementation cell for this recommendation green, which it uses to mark evidence, identified by the legal team, that a recommendation has been clearly implemented. Table row: section 16.2 No. 45, PDF page 411-412.
Source
Responsible bodies
Themes and tags
Who has spoken
- Department of Health and Social Care
Response, delivery statement - DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding