Coroner’s Regulation 28 Reports

Coroner’s Regulation 28 Reports (Prevention of Future Death Reports – PFD)
In certain circumstances a person’s death is reported to HM Coroner to determine whether an Inquest must be held. An Inquest is an investigation into a person’s death to establish, who they were, when they died, where they died and how they came about their death. If any information is revealed as part of the Coroner’s investigation or during the course of the evidence heard at the Inquest, which gives rise to “a concern that circumstances creating a risk of other deaths will occur, or will continue to exist in the future;” and if the Coroner is of the opinion that action needs to be taken, under Paragraph 7 of Schedule 5 of the Coroner and Justice Act 2009, the Coroner has a duty to issue a report to a person, organisation, local authority or government department or agency.

The Coroner’s Regulation 28 Report will set out the concerns and request that action should be taken. The person, body or organisation in receipt of this report then has 56 days to provide the Coroner with their response, to include details of the actions taken and to reassure the Coroner that their concerns have been addressed to prevent future deaths. WWL, as a public organisation, has received Regulation 28 Reports. The Trust takes these reports very seriously and ensures that a response is provided to the Coroner within the required timeframe.

All Regulation 28 Reports and the responses are sent to the Chief Coroner. In most cases the Chief Coroner will publish the reports and responses on the website. Please find a link to the relevant section of the website here.