Recommendation 282

Prevention of future death reports

Coroners should send copies of relevant Rule 43 reports to the Care Quality Commission.

The Coroners and Justice Act 2009 states that where a senior coroner has conducted an investigation and anything has been revealed that indicates a risk of other deaths then the coroner, ‘…must report the matter to a person who the coroner believes has the power to take such action’. (Schedule 5, Paragraph 7). As stated in recommendation 45, the Care Quality Commission already receives prevention of future death reports (previously referred to as rule 43 reports).  In September 2013 the Chief Coroner’s Office sent out additional guidance, Reports to Prevent Future Deaths, to coroners to further support the sharing of this information.  This guidance stated that, ‘coroners should routinely send relevant reports to other organisations, such as … the Care Quality Commission.’


The Care Quality Commission is undertaking an analysis of the information available from coroners’ investigations and inquests, along with other information it already receives relating to expected and unexpected deaths. It will consider the findings of that analysis, including how it could target requests for information from coroners and any burden that collecting this data might impose, working with the Coroners’ Society of England and Wales, the Office of the Chief Coroner, the Ministry of Justice and the Department of Health.

In addition, the Care Quality Commission is working with the Coroners’ Society of England and Wales and the Office of the Chief Coroner in establishing a Memorandum of Understanding with the aim of achieving better working relationships and the sharing of information. The Care Quality Commission continues to receive prevention of future death reports, and received 127 notices between August 2013 and August 2014.

The Care Quality Commission is in the process of developing a single protocol for handling information from Coroners, which includes storing and passing on the information. The protocol also outlines how the information received from Coroners will be fed back into the Care Quality Commission, including incorporation into planning inspections, ‘lessons learned’, reporting back to the Executive Team and external reporting back to Coroner’s offices on any trends or themes that might become apparent in the data.