Recommendation F282: Information for and from inquests
From Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, published 6 February 2013.
Recommendation
Coroners should send copies of relevant Rule 43 reports to the Care Quality Commission.
In brief (written by this site)
In commentary provided in September 2024, the Department of Health and Social Care and NHS England stated that Regulation 28 reports, previously known as Rule 43 reports, are shared with the Care Quality Commission where it is a named respondent or interested organisation, and are also assessed alongside other evidence to identify provider risks (DHSC and NHS England, Feb 2026). In a review published in February 2026, the Thirlwall Inquiry legal team noted that the Coroners' Society of England and Wales had agreed for coroners to provide the commission with copies of any report where concerns regarding care or treatment by a registered provider arise during an inquest (The Thirlwall Inquiry legal team, Feb 2026).
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
Accepted.
The Coroners and Justice Act 2009 states that where a senior coroner has conducted an investigation and anything has been revealed that indicates a risk of other deaths then the coroner, ‘…must report the matter to a person who the coroner believes has the power to take such action’. (Schedule 5, Paragraph 7).
As stated in recommendation 45, the Care Quality Commission already receives prevention of future death reports (previously referred to as rule 43 reports). In September 2013 the Chief Coroner’s Office sent out additional guidance, Reports to prevent Future Deaths, to coroners to further support the sharing of this information. This guidance stated that, ‘Coroners should routinely send relevant reports to other organisations, such as … the Care Quality Commission’
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 say in progress (27 February 2026)
Rule 43 reports, now known as Regulation 28 reports, are shared with the CQC where the CQC is a named respondent or interested organisation.
If CQC are not a named responder/receive the report for information only, under the new Single Assessment Framework the Regulation 28 report will be used alongside other evidence that they collect about a provider(s) to understand the care they are providing and if there any risks we need to be aware of.
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 “Implemented – Ongoing.”. Table row: section 18.2 No. 282, PDF page 576.
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 is the process of developing a single protocol for handling information from Coroners, which includes storing and passing on the information. The protocol also outlines how the information received from Coroners will be fed back into the Care Quality Commission, including incorporation into planning inspections, ‘lessons learned’, reporting back to the Executive Team and external reporting back to Coroner’s offices on any trends or themes that might become apparent in the data.
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 coroners, 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 (27 February 2026)
This recommendation was accepted by the Government.
The Government said in the January 2014 Hard Truths report that the Care Quality Commission already received prevention of future death reports.
The Coroners’ Society of Engand and Wales agreed for coroners to provide the Care Quality Commission with copies of any Regulation 28 report and require a response where concerns about care or treatment provided by a registered provider have been identified during or at the conclusion of the inquest.
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 dated April 2025, published 27 February 2026). The review does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 18.2 No. 282, PDF page 576.
Earlier findings (1)
Thirlwall Inquiry legal team (15 May 2024)
This recommendation was accepted by the Government.
The Government said in the January 2014 Hard Truths report that the Care Quality Commission already received prevention of future death reports.
The Coroners’ Society of England and Wales agreed for coroners to provide the Care Quality Commission with copies of any Regulation 28 report and require a response where concerns about care or treatment provided by a registered provider have been identified during or at the conclusion of the inquest.
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 does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 16.2 No. 282, PDF page 528.
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