- Suggests ways to ensure coronial recommendations are followed and implemented.
- Refers to recommendation by an Independent Advisory Panel on Deaths in Custody report for an independent body to ensure the implementation of coroners’ recommendations.
Following an inquest, coroners don’t reach a legally binding verdict in the way a jury in a criminal trial does. Nor is a binding judgment issued, as in a civil action. Instead, they can only issue prevention of future death (PFDs) reports if they have perceived evidence of failures leading to a death. The chief coroner’s guidance on such reports describes them as vitally important: ‘If society is to learn from deaths... a bereaved family wants to be able to say it was tragic and terrible, but at least it’s less likely to happen to somebody else.’
But evidence suggests that the preventative potential of such reports is not being fully realised, and some families have even criticised the current system as ‘nothing more than a paper exercise’.
