Coroner
Recommendations related to coroner
10
Recommendations
100% accepted
Government Response
Accepted (6)Accepted in Part (4)
Recommendations in This Theme
recommendation across 5 inquiries
Across 5 inquiries
Tagged Recommendations
10 total
P2-52
Accepted in Part
Fuller Inquiry
Share mortuary reports with coroner service
All relevant reports and incidents concerning the mortuary must be made known to the lead local authority manager for the coroner service (and the Senior Coroner if they wish to …
- The government stated in December 2025 that this recommendation on coroner reporting to local authorities on mortuary standards was accepted in principle. Full government …
Ministry of Housing, Com…
P2-54
Accepted in Part
Fuller Inquiry
Local authority contingent body storage plans
Local authorities providing a coroner service must review plans for the provision and operation of contingent body storage, in collaboration with local organisations providing mortuary services.
- The government stated in December 2025 that this recommendation on contingency planning for local authority mortuary capacity was accepted in principle. Full government response …
Ministry of Housing, Com…
IHRD-60
Accepted
Hyponatraemia Inquiry
Coroner Communication Training
There should be training in the communication of appropriate information and documentation to the Coroner's office.
- HSC Trusts reported that training on open disclosure and candour principles had been provided to clinical staff (IHRD Implementation Programme, Department of Health NI, …
HSC Trusts
40
Accepted
Morecambe Bay Investigation
Extend medical examiners to stillbirths
Given that the systematic review of deaths by medical examiners should be in place, as above, we recommend that this system be extended to stillbirths as well as neonatal deaths, …
- In July 2015, the government stated: "We accept these recommendations in principle" (covering recs 39 and 40) but noted that "medical examiners would scrutinise …
Department of Health and…
F273
Accepted in Part
Mid Staffs Inquiry
Information to coroners
The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable the coroner to perform his function, unless a …
- Schedule 5 of the Coroners and Justice Act 2009 confers power on coroners to order the disclosure of evidence, including written statements and documents …
Healthcare providers
F274
Accepted
Mid Staffs Inquiry
Information to coroners
There is an urgent need for unequivocal guidance to be given to trusts and their legal advisers and those handling disclosure of information to coroners, patients and families, as to …
- The National Medical Examiner stated in April 2025 that records of medical examiner scrutiny should be shared with bereaved families where possible, following an …
Department of Health and…
F284
Accepted
Mid Staffs Inquiry
Appointment of assistant deputy coroners
The Lord Chancellor should issue guidance as to the criteria to be adopted in the appointment of assistant deputy coroners.
- DHSC and NHS England stated in April 2025 that action was taken regarding the appointment of assistant coroners following the conclusion of the Mid-Staffordshire …
F285
Accepted
Mid Staffs Inquiry
Appointment of assistant deputy coroners
The Chief Coroner should issue guidance on how to avoid the appearance of bias when assistant deputy coroners are associated with a party in a case.
- DHSC and NHS England stated in April 2025 that the Thirlwall Inquiry has noted action taken in response to this recommendation regarding the appearance …
F45
Accepted in Part
Mid Staffs Inquiry
Use of information about compliance by regulator from: Inquests
The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.
- The Department of Health and Social Care and NHS England stated in April 2025 that this recommendation was superseded by the statutory medical examiner …
CQC
1
Accepted
Hillsborough Panel
Chief Coroner guidance on coroners' records
We recommend that the Lord Chancellor and Secretary of State for Justice invite the Chief Coroner to prepare guidance for all coroners on the appropriate retention and archiving of documents …
Ministry of Justice