The Court of Appeal has imposed an obligation on coroners to make reports under rule 43 of the Coroner's Rules where the evidence clearly calls out for action to be taken. Rule 43 reports are sent to persons or authorities (such as NHS trusts) who may have the power to take action to prevent similar deaths happening in the future. The recipient of a report has a statutory obligation to respond to the coroner. The rule states that the coroner "may" report the matter if he believes that action should be taken to prevent future deaths. In R (on the application of Keith Lewis) (Appellant) v HM Coroner for the Mid & North Division of the County of Shropshire (Respondent) & Secretary of State for Justice (Interested Party) (2009),there was undisputed evidence that the training and equipment given to a prison officer (who failed to enter a cell to provide assistance when he saw an inmate hanging) was utterly inadequate. The Coroner, nonetheless, made no rule 43 report.

The Court of Appeal stated that when the need for action is as plain as this, the coroner must make a report under rule 43 (even though the rule only states that he "may" do so).The Coroners and Justice Act 2009 (when the relevant parts of it come into force in 2012) will have the effect of making a coroner's report mandatory in these circumstances. This decision brings that change forward by over two years.

The court also considered whether the coroner was under a duty to allow the jury's verdict to refer to issues that were only possibly causative of death. In this case, there was no way of knowing whether the prison officer's inaction had caused the death, or whether the prisoner would have died anyway. The most that could be said was that this inaction was possibly a contributory cause of the death. The court ruled that while the coroner was entitled to allow the jury to refer to such issues, he was under no obligation to do so. The language of the court's ruling is unlikely to stop parties demanding the jury's verdict encompasses matters that go beyond issues that caused the death.

The judgment can be accessed here.