Claire Bentley and Debbie Platts look at the fourth summary of reports and responses under Rule 43 of the Coroners Rules published by the Ministry of Justice in March 2011.  It bears thorough reading as it makes clear the trends in reporting by coroners and the issues requiring such reports.

This article focuses on four specific areas:

  • Reports by death types
  • Responses to  Reports
  • Trends
  • Reducing the chances of receiving Rules 43 reports – How can we help?

Reports by Death Types

This summary covers the period 1 April 2010 to 30 September 2010.  During that time coroners issued a Rule 43 report in 175 inquests from 51% of the Coroner Districts in England and Wales.  The percentages of reports according to the main types of death are:

  • Hospital deaths   26%
  • Deaths in custody   13%
  • Community healthcare and emergency services related deaths   12%
  • Road deaths   10%
  • Mental health deaths    8%
  • Drug and medication deaths   3%

The document notes that the percentage number of Rule 43 reports issued in relation to road deaths has reduced.

Responses to Reports

Organisations receiving reports under the provisions of Rule 43 of the Coroners Rules 1984 have 56 days from the date the report is received from the coroner in which to respond.  The response must set out any actions taken as a result of receiving the Rule 43 report, or, if no action has been or is to be taken, an explanation of why not.  This time limit can be extended at the discretion of the reporting coroner but that discretion should not be relied upon.

There were ten organisations who had not responded to reports during the period of this Ministry of Justice summary, (within the 56 day limit) and their details are published in the body of the Ministry of Justice report.  Consequently there is a wider public focus to non compliance.


The outline details of all the reports during the period of the summary can help us to identify trends in reporting.  The main trends apparent in the report are:

Hospital deaths -

  • Staff training
    Several reports point to the absence of both appropriately trained and sufficient numbers of staff, and the need for lessons learned after a death to be shared and implemented
  • Procedures and protocols not being followed
  • Record keeping
  • Communication - Communication concerns are raised in the following areas:
    • Between different hospital departments or specialities
    • Between different staff involved in the patient’s care, including when they change shifts
    • With patients and their families, and
    • With community healthcare providers about follow-up treatment after discharge from hospital

Deaths in custody  - 

  • Medical care of prisoners, particularly those with mental health concerns
  • Communication
  • Prison procedures and protocols not being followed or communicated properly

Community healthcare and emergency services related deaths - 

  • Procedures and protocols not being followed or communicated properly
  • Concerns about the prescribing, dispensing and availability of drugs and other substances.

Reducing the chances of receiving Rule 43 reports – How can we help?

Rule 43 reports are sent by coroners if they feel that actions could still potentially be taken by organisations to help avoid future deaths.  These reports are made at the conclusion of the inquest and accordingly relate to actions or lessons which can be learned arising from that particular inquest on the facts.

To help reduce the chances of receiving a Rule 43 report, any organisation can:

  • fully investigate the circumstances of the death, identify actions that can be undertaken to reduce future deaths and put in place a plan to carry out the actions
  • send a copy of the completed or ongoing action plan to the coroner
  • potentially send a suitable individual from the organisation to speak to the actions which have been put in place, or are to be taken forward, or the “lessons learned” at the inquest itself.

The above can help to provide reassurance to the coroner, other organisations and the family that appropriate consideration has been given to the circumstances of the death, and that appropriate safeguards are in place.

At Bevan Brittan we have substantial experience of inquests and can assist you in all aspects of inquest management - liaising with the coroner, managing witnesses, statement taking, coordination of evidence, management and representation at the inquest as well as post inquest follow up advice.
We can also deal with all other issues which may be linked to inquests such as the police or multi agency investigation, and helping you manage its internal inquiry and investigation.

Finally we can also provide training on a range of issues relating to inquests such as good record keeping, communication skills, attending an inquest as a witness, the relationship between inquests and claims and general inquest law updates.

Our use of cookies

We use necessary cookies to make our site work. We'd also like to set optional analytics cookies to help us improve it. We won't set optional cookies unless you enable them. Using this tool will set a cookie on your device to remember your preferences. For more detailed information about the cookies we use, see our Cookies page.

Necessary cookies

Necessary cookies enable core functionality such as security, network management, and accessibility. You may disable these by changing your browser settings, but this may affect how the website functions.

Analytics cookies

We'd like to set Google Analytics cookies to help us to improve our website by collection and reporting information on how you use it. The cookies collect information in a way that does not directly identify anyone.
For more information on how these cookies work, please see our Cookies page.