TRAINING - Clinical negligence and the Emergency Department
Jan 25 2022
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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:
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:
The document notes that the percentage number of Rule 43 reports issued in relation to road deaths has reduced.
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 -
Deaths in custody -
Community healthcare and emergency services related deaths -
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:
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.