On 20 March 2013, the Ministry of Justice published the 8th Rule 43 Coroners Rules 1984 Report Summary which covers reports and responses from 1 April 2012 to 30 September 2012. Overall, there has been a drop in the number of reports since the last reporting period although hospital deaths are still the largest category, followed by RTAs and mental health related deaths. The Report identifies 3 reports of potentially wider application:

  • A report into the death of a baby who was born prematurely and in respiratory distress and who died shortly after being transferred to hospital. Following a review by the North East Ambulance Service NHS Trust, the decision had been made to include paediatric advanced life support training as a refresher to all their operational staff and additional training measures were put in place. The Coroner concluded that these measures, if implemented elsewhere, could save lives.
  • A report into the death of an employee of Network Rail who was hit by a train whilst carrying out repairs on track. The Coroner had asked Northern Rail to consider additional training for train drivers on the circumstances in which they should sound the horn the fitting of forward facing cameras in the cabs of its trains. Northern Rail confirmed that measures had been taken.
  • A report into the death of a young man who died of a berry aneurism whilst he was being detained at HM Young Offenders Institution (HMYOI) Glen Parva. The man had reported feeling unwell on the Saturday but arrangements were not made for him to be seen until the Sunday afternoon. He collapsed whilst waiting for his GP appointment and died in hospital the following day. The Coroner asked the relevant NHS Trust to consider clarifying how regularly triage clinics are held, what happens when there is an out-of-hours illness and what steps staff should take when prisoners report an illness. The Trust issued new “resting in cell” guidance designed to ensure that prisoners are seen on the same day that they report feeling unwell both during the week and at weekends.