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F283

Information for and from inquests

Mid Staffs Inquiry · Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · Issued 6 February 2013

Government responseDepartment of Health and Social Care: Accepted (Nov 2013)

DeliveryDHSC and NHS England say in progress (Feb 2026)Department of Health and Social Care says in progress (Feb 2015)

Recommendation, verbatim from the inquiry

●Inquiry recommendation

Guidance should be developed for coroners' offices about whom to approach in gathering information about whether to hold an inquest into the death of a patient. This should include contact with the patient's family.

Mid Staffs Inquiry, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · 6 Feb 2013 Source PDF →

Published evidence summary

AI-generated evidence summary

The Department of Health and Social Care and NHS England reported in February 2026 that the Judicial College delivers a training programme for all coroners, annual training is provided for coroners’ officers, and the Chief Coroner provides detailed guidance to coroners on their legal duties, policy, and practice (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team noted in May 2024 that the government had accepted the recommendation, citing previous reports of mandatory and continuation training programmes for coroners (The Thirlwall Inquiry legal team, May 2024).

AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026.

About this summary
This recommendation applies across many organisations. The record above reflects central policy activity; adoption in individual organisations may vary.

Report-level response context

Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.

Government response

●Department of Health and Social Care · Accepted · 19 Nov 2013

Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013

Accepted.
The Judicial College has taken responsibility for training all coroners and coroner’s officers under the remit of the Chief Coroner’s Office from July 2013. The College has already supplied training to coroners on the Coroners and Justice Act 2009 and will develop training for all coroners’ officers on their roles. This will cover how to involve bereaved families when gathering information in connection with the coroner’s investigation. We anticipate that this training will be available from 2014.

Response document: Hard Truths: The Journey to Putting Patients First. Volume Two of the Government Response to the Mid Staffordshire NHS Foundation Trust Public Inquiry: Response to the Inquiry's Recommendations

Site note: This is volume two of "Hard Truths: The Journey to Putting Patients First" (Cm 8777-II), the government's response to the Inquiry's 290 recommendations, published by the Department of Health on GOV.UK on 19 November 2013 and dated to that day here. The PDF the row links to is the accessible edition, whose title page reads "January 2014". The Department of Health has been the Department of Health and Social Care since January 2018. The volume says it includes accounts from each of the national organisations the recommendations name, but it does not mark which passage each organisation wrote, so every row is filed under the Department that published it.

Delivery

●DHSC and NHS England say in progress · 27 Feb 2026

The Judicial College delivers a training programme for all coroners including induction. Annual training is also provided for coroners’ officers.

The Chief Coroner provides detailed Guidance to coroners on various matters relating to the Coroners and Justice Act 2009 to assist coroners with the law and their legal duties, and to provide commentary and advice on policy and practice.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025)

Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Implemented – Ongoing”. Table row: section 18.2 No. 283, PDF page 576.

●Department of Health and Social Care says in progress · 11 Feb 2015

The Judicial College has a programme of mandatory coroner training in place for 2013-14, including 12 courses covering the new legislation and two induction courses. A programme of annual continuation training for coroners began in April 2014 and is ongoing. The Judicial College are also developing plans for coroner officer training. A training needs analysis questionnaire was issued to coroners officers in April 2014 and the Judicial College are using the results to design coroner officer training.

From: Culture Change in the NHS supporting Annex (annex to Culture change in the NHS: applying the lessons of the Francis Inquiries)

Site note: This is the supporting annex published on 11 February 2015 with "Culture change in the NHS: applying the lessons of the Francis Inquiries" (Cm 9009), attached to the GOV.UK page as "Culture change in the NHS supporting annex". The annex has no title page; that title is GOV.UK's and the PDF's own. Its table has four columns (No., Recommendation, Hard Truths Government response, Progress update), and the row carries the Progress update cell. No column says which organisation wrote an update, so the row is filed under the Department of Health (now the Department of Health and Social Care), which published it.

Site note: The Inquiry addressed this recommendation to the Ministry of Justice, not to the Department of Health. The annex gives this update in the Department's publication and does not say who wrote it, so the row is the Department's report of the progress made on it.

What other bodies have found

In their own words. These do not change the delivery statement above.

●Thirlwall Inquiry legal team · 15 May 2024

This recommendation was accepted by the Government.

In the 2015 Culture Change report, the Government said that the Judicial College had in place a programme of mandatory coroner training in place for 2013-14, with a programme of annual continuation training for coroner beginning in April 2014.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024)

Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 16.2 No. 283, PDF page 528-529.

How this page is built

The recommendation and the government responses are verbatim from primary documents. Delivery statements and other bodies' findings are shown in their own words, each with its source. The summary is written by this site and labelled as such. The Index does not paraphrase sources or characterise intent; it records what has been published.