Paragraph 7 of Schedule 5, Coroners and Justice Act 2009, provides coroners with the duty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths.
All reports (formerly known as Rule 43 reports) and responses must be sent to the Chief Coroner. In most cases the Chief Coroner will publish the reports and responses on this website. Details of the procedures are set out in Regulations 28 and 19, Coroners (Investigations) Regulations 2013.
The Chief Coroner’s Office is currently working to upload all Reports made since 25 July 2013. Please ensure you check back with this page on a regular basis.”