When I use a word . . . . Preventing future deaths—problems and solutions

In England and Wales, coroners are legally required to send reports to interested parties when they believe that actions should be taken to prevent deaths other than those on which their conclusions are based. Recipients of the reports are statutorily required to respond to the coroner within 56 days of receiving the report, outlining actions proposed or already taken to tackle the concerns that the coroner has expressed. Similar systems are in operation in Australia and New Zealand. Reports are not, however, uniformly well prepared. Not all recipients respond, and when they do the responses may not be satisfactory. Reports are mainly sent locally and not distributed more widely. Furthermore, recommendations are often not regarded as being sound or practicable or likely to be effective in preventing deaths and injuries. Possible improvements include enhancing the ways in which coroners’ reports are produced and made available, ensuring that responses are forthcoming from all those to whom reports are sent, distributing reports more widely, and preparing systematic reviews of collections of similar reports to reinforce the concerns expressed.