The Ministry of Justice has published its latest summary of reports and responses under Rule 43 of the Coroner’s Rules.

Rule 43 is the power given to a coroner to make reports to organisations requiring them to consider whether changes to their practises could prevent deaths in the future, in circumstances where a coroner feels he has identified a potential problem during an inquest.

Between 1 April and September last year, 210 reports were issued. Hospital deaths resulted in the highest number of reports (75). Also high on the list are reports issued in relation to community healthcare and emergency services (24) and mental health related deaths (21).

Reports across all categories of deaths identify the following as causes for concern:

  • Poor communication (between departments, specialties or teams, members of staff or patients/ families and staff)
  • A lack of procedures or protocols or a failure to follow them
  • Health and safety issues, including the need for first aid training and appropriate risk assessments to be carried out
  • The need to share and implement lessons learned

Those involved in the care of mental health patients should note the specific issues of:

  • The need to be vigilant about the security of patients, especially where they go missing
  • The need to obtain psychiatric assessments at the earliest possible opportunity
  • The need to improve the level of observations

Wider themes were also drawn from specific reports which could be applied to other organisations. Of particular note are the following points:

  • The need to provide warnings and information for English speaking and non-English speaking patients (where appropriate)
  • A general need to establish procedures that comply with National Patient Safety Agency (NPSA) alerts
  • A specific need for compliance with NPSA alerts relating to the dangers surrounding prescribing, dispensing and administering loading doses