Coroners
7
Recommendations
86% accepted
Government Response
Accepted (4)Accepted in Part (2)Awaiting Response (1)
Recommendations in This Theme
recommendation across 3 inquiries
Across 3 inquiries
Tagged Recommendations
7 total
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- The Department of Health and Social Care and NHS England stated in April 2025 that this recommendation was superseded by the statutory medical examiner …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
R2
Historic
Allitt Inquiry
Coroners to send post mortem reports to consultants
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 …
Home Office