What happens to Coroners' reports?

Nearly 600,000 people die in England and Wales every year from a multiplicity of causes, 'natural' or otherwise. Of these in 2022, over 36,000 resulted in a Coroner's Court Inquest, which endeavours to attribute a general cause to the death. 

Coroners are one of the oldest judicial appointments. It can be traced back 910 AD and King Alfred but up to recent times has been a local government function in England and Wales, independent of Central Government and the rest of the judicial system. 

As from 2009, although still located within local government, Coroners have come under the jurisdiction and general direction of the central government Justice Department. This may have both its pros and cons in sensitive cases, where political issues may be involved. In the investigation of deaths, the Coroner works closely with the police and other agencies such as the Health and Safety Executive.

A coroner's court is required when a death is reported to the coroner and an inquest is needed when: 

• The cause of death is unknown 
• The death may have been violent or unnatural 
• The death may have occurred in police custody or prison 
• The cause of death was not found during the post mortem 
• The deceased was in the care of the state at the time of death

The following findings are possible:

• Natural causes 

• Accident or misadventure 

• Suicide 

• Narrative, which enables the Coroner to describe briefly the circumstances by which the death came about 

• Unlawful killing (or lawful killing) 

• Alcohol 

• Drug related 

• Industrial Disease 

• Road Traffic Collision 

• Neglect (usually contributing to another conclusion, eg natural causes) 

• Open, meaning that there is insufficient evidence to decide how the death came about – the case is left open in case further evidence appears. 

In most cases the Coroner sits alone, but in a relatively small number of the more high profile or contentious ones, it it is held with a Jury that decides on the verdict on the Coroner's recommendation. In 2023 there were 474 such (representing 1% of all inquests). In the same year, 891 were suspended and not resumed because they were subject to criminal proceedings. 

As from the Coroners and Justice Act 2009, that inaugurated a 'Chief Coroner' at the Ministry of Justice, Rule 43 reports were replaced by 'Reports on Action to Prevent Future Deaths'.  For short they can be referred to as PFDs or PFD reports or Regulation 28 Reports. The Chief Coroner expects to receive around 600 of these a year and publishes them on his web-site. (See: https://www.judiciary.uk/courts-and-tribunals/coroners-courts/reports-to-prevent-future-deaths/ )  However little is known or collated on the practical result of these recommendations. Which is where the following initiative comes into play.

Death may be inevitable for everyone, but knowing the how and why have long been considered important in creating a safe and healthy environment. The Coroner's Inquest plays a central role in this process and in a relatively few cases, making recommendations for prevention.  Knowing what happens to these is a very grey area that requires further clarity and transparency if they are to be effective. This might include a statutory duty on those individuals or organisations on whom they are served, to indicate what steps have been taken to comply.

The Preventable Deaths Tracker newsletter provides unique summaries of coronial data to help learn lessons from inquests for public health and safety. If you enjoy it, consider supporting this work for only £5.99 a month (£1.38 a week!), you’ll gain access to all articles, the archive, and the comment section.

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Deaths in the NHS: Ambulance Trusts

A matter of life or death

Dr Georgia Richards Nov 28

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Coroners have been sending reports to organisations to take action to prevent future deaths for over 11 years. However, no one is responsible for understanding who receives these reports, whether they respond, and if action is taken. The Preventable Deaths Tracker is changing this: the only platform that provides real-time statistics.

To highlight what the Preventable Deaths Tracker’s databases can do, I’m launching a new series to share specific analyses on the organisations receiving coroner reports. Today, I’m starting with Ambulance Trusts - the service we rely on in emergencies, often matters of life or death.

217 coroners’ reports

There are 11 Ambulance Trusts in England and Wales. Collectively, coroners sent 217 reports to Ambulance Trusts between July 2013 and 24 November 2024. One-fifth (22%) of reports were sent to the Welsh Ambulance Services, and one-tenth (12%) were sent to the London Ambulance Service.

Every organisation that receives a coroners’ report should respond to all (100%) reports by law. The South East Coast and Yorkshire Ambulance Services have the best response rates, with two-thirds (67%) of all their responses published. The London Ambulance Service has the worst response rate, with only one-third (35%) of reports with published responses.

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Trends over time

Ambulance Trusts received the most (16%) reports in 2019, with trends dropping during the COVID-19 pandemic.

Do Ambulance Trusts track their reports?

Organisations don’t publish statistics on how many reports they receive from coroners and what actions they take to prevent future deaths. Sharing this information would build a national learning culture where similar organisations could adopt similar actions.

To understand whether Ambulance Trusts were capturing (and hopefully using) this information, I asked them. The majority (54%) of Ambulance Trusts initially refused to share any information, citing that it was already available via the judiciary website. But as I’ve mentioned before, the entire “system” relies on email exchanges, so not all written reports get published. After explaining this, one-third (36%) of Ambulance Trusts continued to refuse to share any information, including:

1. London Ambulance Service NHS Trust,

2. East Midlands Ambulance Service NHS Trust,

3. East of England Ambulance Service NHS Trust, and

4. Yorkshire Ambulance Service NHS Trust.

The remaining Ambulance Trusts shared all or some of their data. When comparing the information shared with the Judiciary website, three Ambulance Trusts underreported (i.e. the Trusts are missing reports), and two Ambulance Trusts reported more reports (i.e. the judiciary website is missing reports). It’s a mess.

The Welsh Ambulance Services University NHS Trust reported that since 2022, they’re using a national database 'Once for Wales' Datix Cymru system to record its inquest management. So, it’s great to hear work is being done to improve data capture, but English Ambulance Trusts (and the other 2,000+ organisations that receive coroners’ reports) now need to follow.

The Verdict

The lack of any “system” to track and use coroners’ reports is a missed opportunity. Local approaches to improve data capture are a positive start, but a national approach is needed. Until then, the Preventable Deaths Tracker will keep tracking.

 

Hazlitt Overlooked

by Tim Veater.

I woke at two, I woke at six,

To pass the time I read my book.

Try as I may, I could not recall,

One famous name at all, at all.

I wracked my brain which wasn't home,

I knew it had been mentioned in the tome,

I'd checked the index many times,

But nothing matched and nothing chimed.

Then out of the blue the name appeared,

To prove the brain is very weird,

Somehow I remembered it,

That famous writer, Will Hazlitt.

I checked the index yet again,

To prove how stupid I had been;

Low and behold it wasn't there,

No matter where I looked or how I stared.

Despite the mention in the text,

Devoid the index was of poor Hazlitt.

So yet again he had been snubbed,

Just like his writings, all been rubbed.

As in his life he was passed by,

“So who was Hazlitt?” I hear you cry,

A double insult to the man,

Who died two decades ere the book began.

Sam Smiles' 'Self Help' was all the rage,

Sadly it came too late to help the sage.

Of all the exemplars in the book,

He gives not Hazlitt a second look.

Tis said of him, 'One of the greatest essayists

In English language history”,

Yet all his pamphlets are out of print

And Samuel Smiles gives not a hint,

Of Hazlitt's heroic life or trials

Or what lasting legacy he left behind

Upon the age or on the mind

Of Michael Foot, the much maligned!

William Hazlitt :  

https://en.wikipedia.org/wiki/William_Hazlitt

3.12.2024:  "The right to defend itself", continuously repeated by the State Department spokesman and all those who wish to excuse Israel's barbarity and heinous crimes too numerous to mention, has been shorn of meaning. It would appear the concept neutralises every atrocity, justifies any action however illegal or inhumane. Will it now be applicable to all the murderers in the United States? All the defense attorney need do is assert the claim it was 'self defence', however ludecrous, to get off. Of course in refusing to condemn the outrages that continue; to keep supplying the bullets and bombs that kill and maim innocent civilians and its own hostages - not only by accident but by intent and design; to even blocking the Security Council motions and UN demands for a cease-fire; America has alligned itself with a very dark and ominous philosophy for mankind. That there are in war, no moral or legal boundaries; that 'might' alone is right; that the internationally binding principles, agreed after the Second World War no longer apply; that when it comes to, the whole apparatus of the United Nations and its subsidiary organisations, can be made of no effect, by the determined action of a racist, fanatical, apartheid, genocidal regime, so long as it calls itself a 'Jewish State' only 'defending itself'! https://veaterecosan.blogspot.com/

Interesting background to the Southport murders.

It appears the father of the alleged murderer, Axel Rudakubana,  was closely involved in the Rwandan Tutsi genocide and was subsequently represented by Keir Starmer in extradition proceedings in Britain.

Following from: https://threadreaderapp.com/thread/1858128994694045907.html

Dan

@DanTalks1

7h • 12 tweets • 4 min read •  Read on X

The real story behind the Southport murders of these 3 little girls and how @Keir_Starmer played a critical role in it.

This is the real reason why it's being suppressed all over the UK and why even MPs are scared to talk about it.

The murderer Axel Rudakubana on the 29th of July murdered Alice da Silva Aguiar, nine, Bebe King, six, and Elsie Dot Stancombe, seven in cold blood.

Stirring public outcry and was the catalyst behind protests that took place. But who is Axel and why is he in he UK? 

Axel's father is Alphonse Rudakubana.

Alphonse is known and tried by the international criminal court for participation in the Rwandan genocide in the 90s.

Court case below.
ucr.irmct.org/LegalRef/CMSDo…

Alphonse is wanted in connection with the crimes committed here.

Who is the lawyer representing this war criminal wanted for genocide? None other than QC and current PM of the UK @Keir_Starmer .

Keir was the man who represented Alphonse and got his extradition removed and ensured his status and asylum in the UK. 

Keir was in the guardian, publicly advocating for this, alongside benefits and support for Alphonse alongside other refugees.

This is the archive of it.

archive.is/2024.07.31-120…

https://archive.is/2024.07.31-120651/https://www.theguardian.com/uk/2003/feb/11/immigration.immigrationandpublicservices

Keir was involved in the legal case to guarantee Alphonse's asylum here is the case.

refugeecouncil.org.uk/wp-content/upl…

This is why the UK govt have completely suppressed this story and won't let any media or anyone talk about it, and have had police raid anyone talking about this.

The truth is the current PM of the UK was instrumental in ensuring the killers father was given asylum in the UK. 

The blood of the three girls of Southport are on his hands. 

Nigel knows and can't say. Now you know.

The rest is up to you guys. Repost it enough and he goes down. They can't censor X. 

Important additional information.

• •

Monday, 5 August 2024

 Southport Killings: Something very strange going on?

https://veaterecosan.blogspot.com/search?q=Southport