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Coroner

Recommendations related to coroner

10 recommendations 100% accepted

Tag overview

Government Response
Accepted (6)
Accepted in Part (4)
Recommendations in This Theme

recommendation across 5 inquiries

Across 5 inquiries

Fuller Inquiry Hillsborough Panel Hyponatraemia Inquiry Mid Staffs Inquiry Morecambe Bay Investigation

Tagged Recommendations

10 total
P2-52 Accepted in Part Fuller Inquiry

Share mortuary reports with coroner service

All relevant reports and incidents concerning the mortuary must be made known to the lead local authority manager for the coroner service (and the Senior Coroner if they wish to …

- The government stated in December 2025 that this recommendation on coroner reporting to local authorities on mortuary standards was accepted in principle. Full government …
Ministry of Housing, Com…
P2-54 Accepted in Part Fuller Inquiry

Local authority contingent body storage plans

Local authorities providing a coroner service must review plans for the provision and operation of contingent body storage, in collaboration with local organisations providing mortuary services.

- The government stated in December 2025 that this recommendation on contingency planning for local authority mortuary capacity was accepted in principle. Full government response …
Ministry of Housing, Com…
IHRD-60 Accepted Hyponatraemia Inquiry

Coroner Communication Training

There should be training in the communication of appropriate information and documentation to the Coroner's office.

- HSC Trusts reported that training on open disclosure and candour principles had been provided to clinical staff (IHRD Implementation Programme, Department of Health NI, …
HSC Trusts
40 Accepted Morecambe Bay Investigation

Extend medical examiners to stillbirths

Given that the systematic review of deaths by medical examiners should be in place, as above, we recommend that this system be extended to stillbirths as well as neonatal deaths, …

- In July 2015, the government stated: "We accept these recommendations in principle" (covering recs 39 and 40) but noted that "medical examiners would scrutinise …
Department of Health and…
F273 Accepted in Part Mid Staffs Inquiry

Information to coroners

The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable the coroner to perform his function, unless a …

- Schedule 5 of the Coroners and Justice Act 2009 confers power on coroners to order the disclosure of evidence, including written statements and documents …
Healthcare providers
F274 Accepted Mid Staffs Inquiry

Information to coroners

There is an urgent need for unequivocal guidance to be given to trusts and their legal advisers and those handling disclosure of information to coroners, patients and families, as to …

- The National Medical Examiner stated in April 2025 that records of medical examiner scrutiny should be shared with bereaved families where possible, following an …
Department of Health and…
F284 Accepted Mid Staffs Inquiry

Appointment of assistant deputy coroners

The Lord Chancellor should issue guidance as to the criteria to be adopted in the appointment of assistant deputy coroners.

- DHSC and NHS England stated in April 2025 that action was taken regarding the appointment of assistant coroners following the conclusion of the Mid-Staffordshire …
F285 Accepted Mid Staffs Inquiry

Appointment of assistant deputy coroners

The Chief Coroner should issue guidance on how to avoid the appearance of bias when assistant deputy coroners are associated with a party in a case.

- DHSC and NHS England stated in April 2025 that the Thirlwall Inquiry has noted action taken in response to this recommendation regarding the appearance …
F45 Accepted in Part Mid Staffs Inquiry

Use of information about compliance by regulator from: Inquests

The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.

- The Department of Health and Social Care and NHS England stated in April 2025 that this recommendation was superseded by the statutory medical examiner …
CQC
1 Accepted Hillsborough Panel

Chief Coroner guidance on coroners' records

The Panel considers that the implementation of the Coroners and Justice Act 2009 should bring about a more consistent approach to the archiving and availability of transferred records and encourages …

Government reports this recommendation as delivered. Implemented.
Ministry of Justice