Implementing and monitoring the recommendations of previous inquiries and inquests
January 27, 2025
by David Sandiford
In recent weeks the issue of the implementation of recommendations from previous inquiries has received significant media attention. On the 16th January the Home Secretary gave an update on the actions the government will take to protect young people from sexual abuse and grooming gangs.
https://www.gov.uk/government/speeches/next-steps-to-tackle-child-sexual-exploitation
One observation in her statement, that the 2-year inquiry published in February 2022 had examined over 400 recommendations made by previous inquiries and serious case reviews, chimed with my own experience of working on the Tribunal of Inquiry into allegations of child abuse in North Wales. I recall back then reviewing the reports and recommendations of previous inquiries and being struck the by the numbers.
The issue of recommendations and change following inquests has also received recent attention.
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. A recent article in the Times expressed concerns over the effectiveness of PFD’s, the lack of a system to disseminate learning and a lack of central oversight allowing the public to track progress on PFDs.
The new Chief Coroner’s Guidance for Coroners on the Bench published just last Friday ( to which all inquest practitioners should now refer as there are chapters which include, update and expand upon previous Chief Coroner guidance notes ) deals expressly at paragraph 34 with facilitating wider lessons being learnt, advising that:
- All reports and responses about deaths in prisons and other detention centres should as a matter of good practice be sent to HM Inspectorate of Prisons, HM Prison and Probation Service and to the Independent Advisory Panel on Deaths in Custody;
- Coroners should routinely send relevant PFDs to other organisations, such as the Department of Health and Social Care, the Health & Safety Investigation Branch, the CQC, or the Department of Transport.
- Reports directed to NHS England should be sent to: England.Coronersr28@NHS.net
The guidance also states that the PFD reporting power serves an important public health function, however it is no part of the purpose of a PFD report to advance the interests of any person nor to express opprobrium for the shortcomings of others.
So the common themes here are learning the lessons of the past and securing change for the future, but how this is best achieved is where the real challenge lies.
David Sandiford is a Legal 500 ranked leading junior in inquests & inquiries, administrative law & human rights. He has particular experience in cases examining the assessment of risk posed by those under the supervision of state agencies
