Browne Jacobson: Guide to preparing and delivering evidence of organisational learning to the Coroner (15 November 2023)

Summary

Coroners have an important patient safety role under Regulation 28 of the Coroner’s (Investigations) Regulations 2013. This creates a statutory duty for Coroners not just to decide how somebody came by their death but also, where appropriate, to report about that death with a view to preventing future deaths (PFD report).

In certain cases you may wish to provide the Coroner with evidence to explain the outcome of any internal investigation and provide assurance that organisational learning has been, or is being, implemented. This guide from the law firm Browne Jacobson has been produced to assist with the preparation of that evidence, and supplements their previous 'inquest guide for witnesses' and 'guide to writing statements for an inquest'.