At the conclusion of an inquest a coroner can make recommendations known as Rule 43 reports to any organisations if he feels that doing so might prevent future deaths.

In our July Health Legal Update, we reported on the publication by the Ministry of Justice of its summary of reports and responses under Rule 43 for the period from April to September 2011.

Following hot on the heels of that report the Ministry of Justice has just published its summary of reports and responses for the period between October 2011 and March 2012.

The number of reports has increased from 189 in the period April to September 2011 to 233 in the period October 2011 to March 2012 and is the highest since the figures were first published in 2008.

Unsurprisingly the reports were most commonly issued in connection with hospital deaths, accounting for 38 per cent of reports issued.

The best way to minimise the chances of having a Rule 43 report issued against your organisation is to ensure that the recommendations of any serious incident requiring investigation (SIRI) carried out in relation to a case going to an inquest, are robust and have been completed before the inquest begins.

As those of you whose organisations have been unfortunate enough to receive rule 43 order will know, the order requires a response within 56 days explaining what steps have been taken within the organisation to deal with the Coroner’s concerns or why steps are not being taken.

A new report Learning from Death in Custody Inquests: A New framework for Action and Accountability published by the charity Inquest (which monitors deaths in custody), is critical of the current Rule 43 system and in particular the fact that there is no official body which enforces compliance with Rule 43 reports. The charity believes that the lessons to be learned from verdicts and Rule 43 reports are frequently lost because of the lack of enforcement. It will be interesting to see if the new Chief Coroner proposes any changes to the system as a result of the publication of the report.