Patient safety NHSE warns coroners about relying on trusts’ safety reports

Coroners should not rely on trusts’ safety reports as primary or sole evidence for an inquest, NHS England has said, amid concerns some deaths deemed “avoidable” are not even being investigated under the national safety framework.

In an internal newsletter, seen by HSJ, understood to have been circulated to all coroners nationally, NHSE acknowledged “challenges” existed between its patient safety incident response framework (PSIRF) and coronial inquests.

NHSE said in its newsletter that while PSIRF reports can “provide valuable context about wider circumstances and system changes,” they “should not be relied upon as the primary or sole evidence for an inquest”.

It added that PSIRF reports “deliberately exclude activities such as apportioning blame”, determining liability, assessing whether a death is preventable, or identifying cause of death, and focus on systemic insights rather than direct causation.

They also no longer routinely capture witness statements, something coroners have relied upon previously to inform decision-making.

In contrast, coroners are legally required to answer four statutory questions, which often involve establishing causation and examining circumstances around a specific death.

NHSE said: “Some coroners, accustomed to serious incident investigation reports that provided clear chronologies and root-cause analysis, now find that PSIRF outputs, while richer in systemic insight, are lacking the causation detail they expect.”

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Source: HSJ, 26 February 2026