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R2

Coroners to send post mortem reports to consultants

Allitt Inquiry · The Allitt Inquiry Report · Issued 11 February 1994 · Addressed to: Home Office

Government responseDepartment of Health and Social Care: Accepted in part (Nov 1994)

DeliveryDHSC and NHS England state no delivery position (Feb 2026)

Recommendation, verbatim from the inquiry

●Inquiry recommendation

We recommend that in every case Coroners should send copies of post mortem reports to any consultant who has been involved in the patient's care prior to death whether or not demanded under Rule 57 of the Coroner's Rules 1984 (para 4.2.9)

Allitt Inquiry, The Allitt Inquiry Report · 11 Feb 1994 Source PDF →

Government response

●Department of Health and Social Care · Accepted in part · 2 Nov 1994

Words of: Virginia Bottomley, Secretary of State for Health, reporting the Home Secretary's action, in a written answer to Richard Spring MP, House of Commons, 2 November 1994

Recommendation 2. We recommend that in every case Coroners should send copies of post mortem reports to any consultant who has been involved in the patient's care prior to death whether or not demanded under Rule 57 of the Coroner's Rules 1984. My right hon. and learned Friend the Home Secretary, in whose area of responsibility this recommendation falls, intends to commend the principles of the recommendation in a circular to be issued to all coroners in England and Wales later this month.

Extract from: Allitt Report, HC Deb 02 November 1994 vol 248 cc1232-4W

Earlier statement from Department of Health and Social Care (1)

●Department of Health and Social Care · Accepted · 11 Feb 1994

Words of: Virginia Bottomley, Secretary of State for Health, reporting the Home Secretary's acceptance, in a statement to the House of Commons, 11 February 1994

The report makes 12 detailed recommendations to tighten procedures to safeguard children in hospital. I have instructed immediate action to be taken on the 11 that are my responsibility. The Home Secretary has accepted the recommendation concerning coroners. I have placed in the Libraries of both Houses a paper setting out the detailed response to each recommendation.

Extract from: Beverly Allitt (Report), HC Deb 11 February 1994 vol 237 cc586-93

Delivery

●DHSC and NHS England state no delivery position · 27 Feb 2026

This recommendation has been superseded by legislative reform that has taken place, particularly as a result of the changes introduced by the Coroners and Justice Act 2009 and the Health and Care Act 2022, and associated updates to statutory and operational guidance for child death reviews. Further detail is included below on this in Recommendation 3.

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 “Superseded”. Table row: section 3.2 No. 2, PDF page 14.

What other bodies have found

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

●Thirlwall Inquiry legal team · 15 May 2024

In November 1994, the Secretary of State for Health said that the Home Secretary intended to commend this recommendation in a circular to be issued to all coroners in England and Wales later that month.

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 3.2 No. 2, PDF page 14.

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.