Preventing future deaths
The Coroner has a legal power and duty to write a report following an inquest if it appears there is a risk of other deaths occurring in similar circumstances.
The report is sent to the people or organisations who are in a position to take action to reduce the risk. They then must reply within 56 days to say what action they plan to take.
We will send a copy of the Coroner's report and the replies we receive to the family. The report, or a summary or its key findings, will be posted on the Chief Coroner's website