Sometimes an inquest will show that something could be done to prevent other deaths. If so, the Coroner must write a report drawing this to the attention of an organisation (or person) that may have the power to take action. This is called a 'report to prevent future deaths'.
The organisation must send the Coroner a written response to the report. If it does not respond within 56 days, stating what action it has taken, the Coroner will follow up the matter with the organisation, and may inform the Chief Coroner of the failure to respond. The Coroner must send the report and response to the Chief Coroner. The Chief Coroner issues a summary of these reports, which is published on the Judiciary website.
The Coroner's office may send you a copy of the report, and the response.
