The Ministry of Justice has just published its latest summary of Reports and Responses under Rule 43 of the Coroners Rules. The summary covers the period 1 October 2010 – 31 March 2011 and provides an insight into the serious issues that are revealed by inquests and also illustrates a very uneven approach on the part of coroners to the use of their power under Rule 43.

Rule 43 provides that if, at an inquest into a person’s death, a coroner hears evidence that  “gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist in the future; and in the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances” the coroner may report the circumstances to whoever may be able to take remedial action. There is an obligation on the person receiving the report to respond formally to the coroner and in that response details must be given of what action is being taken or an explanation provided of why no action is proposed.  The power is a very valuable one in helping ensure that lessons are learned  - which is often a driving concern of the families of victims in many inquests.

A number of interesting points emerge from the Ministry of Justice’s current summary:

*Numbers of reports – 189 reports were made during the period, which is broadly consistent with the numbers made during previous periods since July 2008 when Rule 43 was amended to take its current form. This is a strikingly small number when set against the number of inquests opened each year – 31,000 in 2010 – and one explanation for this may be that many coroners have not fully embraced the power that Rule 43 gives to them.

* Categories of death reported on – the summary analyses the categories of death under very broad headings and the category which most frequently has led to reports is “hospital deaths”, comprising around 30% of all reports. This is wholly consistent with numbers during previous periods. Next most common were “community healthcare and emergency service related deaths” (13%), “road deaths” (12%) and deaths in custody (11%).

* Issues identified in reports – in relation to hospital deaths, the summary indentifies the comment trends as “staff training, absence, or an apparent lack of staff awareness, of procedures and protocols, staff failing to follow such procedures and protocols, inaccuracies or omissions in record keeping, and concerns about communication”. Communication issues, absences of procedures and protocols or failure to follow procedures and protocols are also a common theme in reports into the other categories of death reported on.

* Responses to reports – the Ministry of Justice analysis is that many organisations “continue to take seriously the concerns that are brought to their attention” and set out in detail in their responses action which has been taken.

The summary also identifies the coroners districts from which reports are issued and what is revealed is particularly striking. There are 114 coroner districts in England and Wales and in the period covered by the summary, reports were issued from 59 different districts. That is consistent with the experience in other periods and it is on the face of it surprising – a broader range of districts might be expected to have issued reports. But the figure for the overall total masks the fact that a very small number of coroners districts issue a very high proportion of the reports: just one district, Greater Manchester (South) has issued approximately 8% of all of the rule 43 reports made since July 2008 with three other districts, South Staffordshire, Cardiff and the Vale of Glamorgan and Greater Manchester (City) accounting for a further 5% each of the total. The Ministry of Justice explanation for the number of reports issued by a coroner – that it is “largely determined by the nature of the deaths he or she investigates and whether he or she believes that action could be taken to prevent future deaths” – is wholly inadequate to explain the vast disparity shown by the figures. The explanation in fact is that there is great inconsistency of approach between coroners, allied to, it appears, a broad lack of understanding of the Rule 43 power.

Although not reflected in the summary, the Ministry of Justice has in fact recognised the need to tackle these problems. In a recent article in PoliticsHome, Jonathan Djanogly the Justice Minister, talking about the reforms to the coronial system that the Government is bringing forward, said that the reforms will address “inconsistencies in the service that is provided” and will include “specific regulations about the training that coroners must receive”. It is to be hoped that these changes will be effective and that in future better use will be made of the Rule 43 power.