Source · Select Committees · Justice Committee
Recommendation 25
25
Paragraph: 207
The system for the Coroner Service to contribute to improvements in public safety is under-developed.
Conclusion
The system for the Coroner Service to contribute to improvements in public safety is under-developed. The absence of follow up to coroners’ ‘prevention of future deaths reports’ is a missed opportunity. The Ministry of Justice should consider setting up an independent office to report on emerging issues raised by coroners and juries; and liaise with regulators, (for example the Health and Safety Executive, the Independent Office for Police Conduct, the Prisons and Probation Ombudsman, the Care Quality Commission, Highways Authorities, and Air and Rail safety bodies) and others, to follow up on actions promised to coroners and to report publicly where insufficient action has been promised or implemented. As an alternative a new Coroner Service Inspectorate could be given this role.
Paragraph Reference:
207
Government Response
Acknowledged
HM Government
Acknowledged
The Government considers that coroners’ PFD reports are a vital tool in ensuring that lessons are learnt and that mitigations are put in place to prevent the risk of future harm or deaths. We are also aware that government departments, regulators and others take very seriously what they say in their responses to coroners’ PFD reports about the actions they will take. Nevertheless, the Government recognises that there is more that can be done in this space to ensure that PFD reports actively contribute to improvements in public safety. We will consider options available alongside the Committee’s recommendation on an Inspectorate of Coroner Services. We are therefore not in a position to accept the recommendation at this stage.