Coroners issue record number of Rule 43 reports

Coroners in England and Wales issued 233 Rule 43 reports between 1 October 2011 and 31 March 2012, a record for a six-month period since the Ministry of Justice began reporting four years ago.

The MoJ’s summary revealed that hospital deaths accounted for 88 reports issued (38%). This was followed by road deaths (30 reports) and mental health related deaths (27 reports).

This is the first time that mental health related deaths have become one of the top three categories.

Other major areas for reports included community health care and emergency services related deaths (22 reports), care home deaths (14) and deaths in custody (12).

Under Rule 43 of the Coroners Rules 1984 – as amended by the Coroners (Amendment) Rules 2008 – coroners have a wider remit to make reports to prevent future deaths. Persons sent a copy of the report must respond to the coroner within 56 days.

The MoJ summary said Rule 43 reports were sent to 120 NHS hospitals and trusts, 46 individual ministers/central Government departments, and 40 regulatory bodies and trade associations.

Local authorities were sent reports on 28 occasions, while care and nursing homes received 25.

On the increase in mental health related deaths, the MoJ said: “A number of reports cite communications issues, particularly between different agencies and hospital departments. They also raise the importance of training staff in caring for patients at risk of self harm.”

In relation to deaths in hospitals, the reports identified concerns over policies and practices in relation to note taking, staffing, training, communication and handover and the recording of medications.

The Ministry added: “As in previous bulletins, reports across all categories of deaths often identify communication and the lack of or the failure to follow procedures and protocols as major concerns.

“They also highlight health and safety issues including the need for first aid training and for appropriate risk assessments to be carried out. A common request across all categories of deaths is the need to share and implement lessons learned.”

The MoJ’s report includes information on those Rule 43 reports which have wider implications beyond the specific case.