Summary of Reports under Rule 43 of the Coroners' Rules
Sixth Report: For period 1 April 2011 - 30 September 2011
Published by the Ministry of Justice - May 2012
http://www.justice.gov.uk/downloads/publications/policy/moj/summary-rule-43.pdf
Coroner's Rule 43 aims to prevent deaths
Every six months, the Ministry of Justice publishes a summary of Coroners' Rule 43 recommendations which have been made by local coroner's with the intention of preventing deaths and learning lessons from the cause of death.
Sixth Report: For period 1 April 2011 - 30 September 2011
Published by the Ministry of Justice - May 2012
http://www.justice.gov.uk/downloads/publications/policy/moj/summary-rule-43.pdf
Coroner's Rule 43 aims to prevent deaths
Every six months, the Ministry of Justice publishes a summary of Coroners' Rule 43 recommendations which have been made by local coroner's with the intention of preventing deaths and learning lessons from the cause of death.
NEW LEGAL FRAMEWORK
Reports to prevent future deaths are made under the Coroners and Justice Act 2009 and secondary legislation made in accordance with the Act: The Coroners (Investigations) Regulations 2013 and the Coroner's (Inquests) Rules 2013. From 25 July 2013, the new Legislation and Regulations replaced Rule 43.
With effect from 17 July 2008, the amended Rule 43 provided that:
Reports to prevent future deaths are made under the Coroners and Justice Act 2009 and secondary legislation made in accordance with the Act: The Coroners (Investigations) Regulations 2013 and the Coroner's (Inquests) Rules 2013. From 25 July 2013, the new Legislation and Regulations replaced Rule 43.
With effect from 17 July 2008, the amended Rule 43 provided that:
- Coroners have a wider remit to make reports to prevent future deaths. It does not have to be a similar death
- A person who receives a report must send the Coroner a written response within 56 days
- Coroners must provide interested persons to the inquest, and the Lord Chancellor, with a copy of the report and the response
- Coroners may send a copy of the report and the response to any other person or organisation with an interest
- The Lord Chancellor may publish the report and response, or a summary of them
- The Lord Chancellor may send a copy of the report and the response to any other person or organisation with an interest (other than a person who has already been sent the report and response by the coroner)
- The statutory instruments concerning the Coroner's Regulations can be viewed at the following link:
www.legislation.gov.uk/uksi/2013/1629/part/7/made
THE ROLE OF INQUESTS AND RULE 43
There are many valuable lessons learned from these inquests. The purpose of an inquest is not to apportion blame, but to answer four questions:
A Coroner does not make a finding of criminal or civil liability, although if that becomes a matter for the courts later, the Coroner's judgment will have an effect upon whether a medical negligence compensation claim, or similar case, could be pursued.
The verdicts of cause of death available to a coroner include:
One of the powers available to a Coroner is the power to make a Rule 43 Report.
If the Coroner feels that the evidence gives rise to a concern that circumstances creating a risk of other deaths will occur or continue to exist, he/she may make a Rule 43 Report which is sent to the organisation that has responsibility for the circumstances. A recipient of a Rule 43 Report must send a written response within 56 days.
The response must give details of any action which has been or is proposed will be taken, or provide an explanation when no action is proposed.
Between July 2008 and March 2009, 207 Rule 43 Reports were made in England and Wales, of which the majority, 31% (78), were sent to NHS Hospitals and Trusts.
Rule 43 Reports may offer some assurance that the circumstances which brought about the death are being addressed, and that future deaths may be avoided.
With thanks to JMW Solicitors, AvMA and the Ministry of Justice)
There are many valuable lessons learned from these inquests. The purpose of an inquest is not to apportion blame, but to answer four questions:
- Who died
- When they died
- Where they died
- How they died
A Coroner does not make a finding of criminal or civil liability, although if that becomes a matter for the courts later, the Coroner's judgment will have an effect upon whether a medical negligence compensation claim, or similar case, could be pursued.
The verdicts of cause of death available to a coroner include:
- Natural causes
- Accident / misadventure
- Neglect contributing to the death
- Unlawful killing
One of the powers available to a Coroner is the power to make a Rule 43 Report.
If the Coroner feels that the evidence gives rise to a concern that circumstances creating a risk of other deaths will occur or continue to exist, he/she may make a Rule 43 Report which is sent to the organisation that has responsibility for the circumstances. A recipient of a Rule 43 Report must send a written response within 56 days.
The response must give details of any action which has been or is proposed will be taken, or provide an explanation when no action is proposed.
Between July 2008 and March 2009, 207 Rule 43 Reports were made in England and Wales, of which the majority, 31% (78), were sent to NHS Hospitals and Trusts.
Rule 43 Reports may offer some assurance that the circumstances which brought about the death are being addressed, and that future deaths may be avoided.
With thanks to JMW Solicitors, AvMA and the Ministry of Justice)
THE HAPIA PROJECT
The aim of this project is to gather information about Rule 43 recommendations made in relation to deaths that occur during the process of heath care, and to build local knowledge about causes of deaths in the NHS that result in inquests. The project aims to share recommendations made, and the action taken by the local NHS and related bodies:
The site has contact details for the Chief Executive of the organisation to which the Coroner's Rule 43 recommendation has been made, and contact details for the CCG, OSC and LINk/HealthWatch for the area.
After a coroner makes a Rule 43 recommendation and details are published by the Minister of Justice, we shall ask the body to which it has been made what their response has been, and put their response on the website.
We shall then ask the CCG, HWBB, the OSC and the LINk/HealthWatch if they have monitored the situation and if they are satisfied that action has been taken to prevent further deaths.
We shall also, in time, let the Coroner's know so that they can be kept informed about whether their Rule 43 recommendations are being implemented.
HEALTHWATCH AND PUBLIC INVOLVEMENT ASSOCIATION
Formerly The National Association of LINks Members
www.hapia2013.org
The aim of this project is to gather information about Rule 43 recommendations made in relation to deaths that occur during the process of heath care, and to build local knowledge about causes of deaths in the NHS that result in inquests. The project aims to share recommendations made, and the action taken by the local NHS and related bodies:
- LINks and HealthWatch (the bodies that represent local people in the NHS social care)
- Clinical Commissioning Groups (CCGs) - the bodies that commission local health services
- Overview and Scrutiny Committees - the bodies that can call local health services to account
- The new Health and Wellbeing Boards which from 01 April 2013, will have a strategic role in
The site has contact details for the Chief Executive of the organisation to which the Coroner's Rule 43 recommendation has been made, and contact details for the CCG, OSC and LINk/HealthWatch for the area.
After a coroner makes a Rule 43 recommendation and details are published by the Minister of Justice, we shall ask the body to which it has been made what their response has been, and put their response on the website.
We shall then ask the CCG, HWBB, the OSC and the LINk/HealthWatch if they have monitored the situation and if they are satisfied that action has been taken to prevent further deaths.
We shall also, in time, let the Coroner's know so that they can be kept informed about whether their Rule 43 recommendations are being implemented.
HEALTHWATCH AND PUBLIC INVOLVEMENT ASSOCIATION
Formerly The National Association of LINks Members
www.hapia2013.org
