As readers will be aware coroners have a wide remit to make reports (known as Rule 43 reports) to prevent future deaths. Any organisation that receives such a report must respond to the coroner within 56 days setting out the steps it intends to take to deal with the coroner’s concerns or why it intends to take no action.

The Ministry of Justice has produced a summary bulletin which covers rule 43 reports received by the Lord Chancellor between 17 July 2008 and 31 March 2009.

Of 207 Rule 43 reports issued 28 per cent covered hospital deaths, mental health related deaths, community healthcare and emergency services related deaths and drug and medication related deaths.

Many of the reports written in respect of hospital deaths mention the need for better communication and procedures within hospitals. The majority of the reports are very specific and relate to a local situation or organisation. However some Rule 43 reports have precipitated a potential wider policy impact, for example:

  • the need for a national allergy service;
  • a more cohesive out of hours medical service relating to call handling;
  • greater emphasis on designing distinctive safety features on medicine packaging in order to avoid confusion; and
  • empowerment of GPs to make direct referrals to a psychiatric hospital where the GP is seriously concerned.

It can be seen that “offenders” who do not respond to the Rule 43 report within 56 days are named and shamed at Annex B!

The report can be accessed here.