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16 January 2014

This week the Chief Coroner’s Office has announced that reports made by coroners to help prevent future deaths will now be routinely published online. 'Preventing future deaths' reports can be made by coroners at the end of an inquest for the benefit of individuals, organisations or public bodies. For the first time they will now be easily available to any member of the public on a dedicated website.

Since the Coroners and Justice Act came into force in July last year, all coroners’ reports and responses from public authorities and institutions have had to be sent to the Chief Coroner.

INQUEST first recommended that these be collated and published nearly ten years ago. During the parliamentary debates on the Coroners and Justice Bill we worked closely with MPs and Peers to make sure this would happen. In 2012 INQUEST published Learning from Death in Custody Inquests: A New Framework for Action and Accountability: a groundbreaking report highlighting the serious flaws in the learning process following an inquest into a death in custody or following contact with state agents.

In the report INQUEST’s co-directors Deborah Coles and Helen Shaw argue that the absence of a mechanism to capture and act upon the rich seam of data available from well conducted and costly inquests leads to unnecessary further loss of life. One of the key conclusions was that publication and access to coroners’ reports was vital to ensure that relevant agencies and institutions benefit fully from the insights provided by this data.

Alongside this important initiative must be the proper auditing and monitoring of actions taken by the authorities and others in response to these reports.

Filed under: Chief Coroner, Inquests, reform
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