Recommendation R2: Coroners to send post mortem reports to consultants
From The Allitt Inquiry Report, published 11 February 1994.
Recommendation
We recommend that in every case Coroners should send copies of post mortem reports to any consultant who has been involved in the patient's care prior to death whether or not demanded under Rule 57 of the Coroner's Rules 1984 (para 4.2.9)
Government response
Recommendation 2. We recommend that in every case Coroners should send copies of post mortem reports to any consultant who has been involved in the patient's care prior to death whether or not demanded under Rule 57 of the Coroner's Rules 1984. My right hon. and learned Friend the Home Secretary, in whose area of responsibility this recommendation falls, intends to commend the principles of the recommendation in a circular to be issued to all coroners in England and Wales later this month.
Earlier statement from Department of Health and Social Care (1)
The report makes 12 detailed recommendations to tighten procedures to safeguard children in hospital. I have instructed immediate action to be taken on the 11 that are my responsibility. The Home Secretary has accepted the recommendation concerning coroners. I have placed in the Libraries of both Houses a paper setting out the detailed response to each recommendation.
Delivery
DHSC and NHS England state no delivery position (27 February 2026)
This recommendation has been superseded by legislative reform that has taken place, particularly as a result of the changes introduced by the Coroners and Justice Act 2009 and the Health and Care Act 2022, and associated updates to statutory and operational guidance for child death reviews. Further detail is included below on this in Recommendation 3.
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 Their reviewed extent of implementation reads “Superseded”.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 3.2 No. 2, PDF page 14.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry legal team (15 May 2024)
In November 1994, the Secretary of State for Health said that the Home Secretary intended to commend this recommendation in a circular to be issued to all coroners in England and Wales later that month.
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 3.2 No. 2, PDF page 14.
Responsible bodies
Themes and tags
Who has spoken
- Department of Health and Social Care
Response - DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding