Health and Safety
Executive / Commission
Enforcement guide
1. Inquests must be held in the circumstances outlined in section 8(1) of the Coroners Act 1988, namely:
2. If a public inquiryis held that adequately investigates the cause(s) of death, it may not be necessary to resume the inquest1.
3. Until Lord Cullen’s inquiry into the rail disaster at Ladbroke Grove, prosecutions in England and Wales always took place before public inquiries. This may not now always be the case. Much will depend on the need to quickly identify the causes of a disaster and put in place measures to prevent a recurrence.
4. Section 11(5)(b) of the Coroners Act 1988 and Rule 36 of the Coroners Rules 1984 confine the ambit of an inquest’s findings to the identity of the deceased and to “how, when and where” he came by his death. By Rule 36(2), the Coroner and/or a jury are prohibited from expressing an opinion on any other matter2. Rule 42 of the Rules prohibits an inquest verdict being framed in such a way as to appear to determine any question of criminal liability on the part of a named person or civil liability.
5. Historically, the scope of “how” the deceased came by his death was not defined and was interpreted in different ways. In R v HM Coroner for North Humberside and Scunthorpe (ex parte Jamieson)3, the Court of Appeal held that the phrase “how the deceased came by his death” was limited and was to be confined to the question of “by what means” the deceased died.
6. In R v HM Coroner for Inner London West District ex parte Dallaglio4 (the ‘Marchioness’ case), the Court of Appeal appeared to draw back from such a strict interpretation and instead encouraged considerable flexibility in the discretion of Coroners as to the scope of the inquest. The Court held that “the inquiry is almost bound to stretch wider than strictly required for the purposes of a verdict. How much wider is pre-eminently a matter for the coroner”5.
7. The scope of a ‘standard’ inquest is therefore no longer as clear. Coroners would appear to have a wide discretion in determining the scope of their inquiry and this has led in practice to some uncertainty, as Coroners take very different views as to how wide their inquiries should be. See below for further guidance on the discretion of Coroners.
8. Where employees (or other emanations) of the state potentially bear responsibility for loss of life (whether by their actions or omissions), the right to life in Article 2 of the European Convention on Human Rights (ECHR)6 may be engaged. For Article 2 to be engaged, there must be reasonable grounds for thinking that the death may have resulted from a wrongful act on behalf of the state7. An example might be a death in custody, either in prison or under police detention.
9. In such a case, the state is under an obligation to initiate an effective public investigation by an independent body. The House of Lords has ruled that, while a criminal investigation and prosecution may not discharge this obligation, an inquest is likely to do so. The inquest must, however, determine not only the identity of the deceased and when, where and how the death occurred, but also in what circumstances8. The limited ambit of a ‘standard’ inquest will not satisfy the obligation on the state.
10. Whether the enhanced form of inquest will be required will depend on the precise circumstances of the particular case9. Only those inquests that are concerned with a possible breach of Article 2 by an agent of the state have this wider scope; other types of inquest can be more limited10. The Coroner’s decision will determine the questions s/he will need to address during the inquest and will have an impact on the assistance that you provide to the Coroner.
[Section 42 (Legal professional privilege) exemption Freedom of Information Act 2000]
16. The chronology of proceedings will depend on:
17. Section 8(1) of the Coroners Act 1988 requires a Coroner to hold an inquest as soon as practicable following a death, and s/he is not permitted by the Rules to adjourn an inquest for the sole reason that criminal proceedings arising from the death have commenced14. However, the Coroner must adjourn where certain proceedings15, including those relating to manslaughter and corporate manslaughter, are ongoing. Therefore, where the police investigate a work-related death and this leads to a file being submitted to the CPS, the inquest will be formally opened and adjourned pending the outcome of the police investigation and the CPS prosecution (if any).
18. It is advisable to liaise with the Coroner whenever a potential health and safety prosecution is pending following a death. If a Coroner seeks to adjourn an inquest until after an HSE prosecution is complete, inspectors are advised to seek advice from their legal liaison point and, if necessary, from Legal Adviser’s Office.
19. HSE prosecutions will generally take place after the conclusion of the inquest16. It is HSE policy that a final decision on enforcement action will not normally be made until after the inquest is held17. The policy is not designed so as to afford HSE (or, indeed, potential defendants) the opportunity to test the available evidence in advance of any enforcement proceedings; rather, it recognises that:
20. HSE must be mindful of the fact that a jury could return a verdict of unlawful killing, in which case the CPS may reconsider whether there is sufficient evidence to bring a prosecution for gross negligence manslaughter18. HSE’s policy is designed to prevent a repeat of the circumstances that occurred in R v Beedie19. In that case, a manslaughter conviction was quashed, as the accused had already been prosecuted for a health and safety offence relating to the defective state of a gas installation, which had resulted in the death. Consequently, the second (manslaughter) prosecution should have been stayed as an abuse of process.
21. This approach also underpins the effective working of the Work-related Deaths Protocol and should inform any decision on disclosure of investigatory material prior to an inquest.
22. Coroners may seek to persuade HSE that a decision on enforcement action and any subsequent health and safety prosecution should proceed before the inquest on the basis that:
23. This course may appear attractive as it could reduce the length and the cost of an inquest and, with the interests of the victim’s family especially in mind, it would mean that any prosecution would take place earlier than would otherwise be the case.
24. However, HSE investigations and subsequent proceedings are generally directed towards the issue of risk and may therefore not explore all the issues that are relevant to the inquest or which the bereaved wish to know about. The death of a person may be pleaded as an aggravating feature in a health and safety prosecution, but it does not form an essential element of the offence. The statutory duty for investigating the cause of death remains with the Coroner.
25. Furthermore, proceeding with the prosecution before the inquest carries with it the type of risk that occurred in Beedie (see above) and is contrary to the Work-related Deaths Protocol; doing so should therefore normally be avoided.
26. Given the usual order of proceedings, and in order that the inquest and any HSE prosecution can progress as quickly as possible, it is important that the Work-related Deaths Protocol operates effectively and HSE is involved in, and consulted on, any police-led investigation. Witness statements should be obtained while the evidence is still fresh in the minds of witnesses, and evidence shared between HSE and the police so that early decisions on prosecutions can be made. HSE should also offer assistance to the Coroner, in line with the [Memorandum of Understanding SE218] (‘MoU’) with the Coroners’ Society. It is important for HSE to be able to provide a reasonable justification for the passage of time.
27. There may be exceptional circumstances in which HSE wishes to proceed with a prosecution before the inquest. In such circumstances, where the risk of a Beedie-type situation are insignificant and it is in the interests of justice to do so, HSE may request that the inquest be adjourned. Unlike the police and the Director of Public Prosecutions, HSE has no statutory power to intervene and seek to adjourn the inquest pending the conclusion of criminal proceedings. However, the Coroners’ Society has agreed in the MoU that Coroners should consider this request in line with section 16(1)(b) of the Coroners Act 198820.
28. Only in exceptional circumstances will an HSE prosecution precede the inquest. A CPS decision not to bring a manslaughter charge, or the delay that holding the inquest first will cause in bringing a prosecution, will not in themselves be sufficient to constitute ‘exceptional circumstances’. It is not for the Coroner to attempt to direct HSE to act contrary to existing case law and the Protocol in this respect. In all cases where you consider that the particular circumstances of the investigation (such as exceptional delays in reaching the CPS’s decision) may make it appropriate to take a prosecution before the inquest, you should first contact Legal Adviser’s Office (LAO) for advice. What the interests of justice require in any particular investigation will depend upon the particular facts and circumstances. For example, exceptional delay by the CPS in making its decision may indicate that the matter is very finely balanced and that a verdict of unlawful killing is a possibility. If LAO is content that HSE proceed, you should first obtain the views of the bereaved before approaching the Coroner.
29. All inquests may be held with a jury. However, an inquest must be held with a jury in a number of circumstances, including where:
30. If the Coroner consults you and other properly interested persons on the issue of whether to summon a jury, it may be necessary to remind him/her of R v Poplar Coroner, ex parte Chaudhry22, where it was held that it is the Coroner’s task to consider whether there is reason to suspect that the death occurred in “circumstances the continuance or possible recurrence of which is prejudicial to the health or safety of the public”. If it appears to the Coroner that there are such circumstances, then s/he must summon a jury.
31. As indicated above, the purpose of the inquest is to determine who the deceased was and how, when and where s/he came about his/her death23. The verdict must not be framed in such a way as to appear to determine any question of criminal liability on the part of a named person or civil liability24.
32. Rules 19(b)(ii) and 20(2)(f) of the Coroners Rules 1984 require the Coroner, if so requested by an HSE inspector, to notify the inspector of the date, hour and place of the inquest. It is therefore important that you write to the Coroner and ask to be notified.
33. There is a similar requirement placed on the Coroner25 to inform you, unless impracticable, of the date, hour and place of any post mortem examination if the death may have been caused by a reportable accident or disease.
34. It is extremely rare and generally unnecessary for an HSE inspector to attend a post mortem. As only medically qualified persons are entitled to attend, in rare cases where the Coroner does ask that an HSE inspector attends in order to assist him, the request will need to be passed to a Medical Inspector to consider.
35. See The Coroner and HSE for further guidance on liaising with, and providing assistance to, the Coroner.
36. In some cases, the Coroner may decide to hold a pre-inquest hearing. Such hearings are not a statutory requirement but have been accepted as a sensible method of administering the inquest process. They do not strictly form part of the inquest itself and, therefore, the purpose and form of the hearing are matters for the Coroner.
37. A pre-inquest hearing may be an opportunity for you and other properly interested persons to ascertain from the Coroner the ambit of the inquest, i.e. those issues which the Coroner considers relevant. To a large extent, this will depend on whether an extended form of inquest is required to fulfil the obligations on the state under Article 2 of the ECHR (see ‘Article 2’ inquests above).
38. If you have not already been provided with a list of witnesses, the pre-inquest hearing may also allow you to find out which witnesses will be called. You may wish to contact the Coroner prior to the hearing to determine whether s/he requires any further assistance from you. The Coroner should, however, be dissuaded from using the hearing to pressure you into undertaking further enquiries on his/her behalf (see the section The Coroner and HSE – Working with the Coroner). You should also be aware that the Coroner has limited powers in relation to disclosure (see The Coroner and HSE – Disclosure of information by the Coroner).
39. Coroners have certain limited powers to summons a person to attend the inquest (although not in relation to a pre-inquest hearing). They can summons any person within their jurisdiction (i.e. their area), whom they believe has evidence that is relevant to the scope of the inquest, to attend to give that evidence in person. The proper service of a summons is dictated by the Civil Procedure Rules.
40. Where a person within the jurisdiction is properly summonsed and fails to appear after being called three times, the Coroner can impose a fine of up to £1000. However, s/he must first hear evidence of proper service of the summons. Coroners must apply to the High Court or a county court for a summons to compel the production of any document.
41. Coroners do not have the power to summons a person from outside their jurisdictional area. The High Court and county courts have the power to issue a summons requiring the attendance of a person to give evidence or produce listed documents on a given date26. That power can be used on behalf of inferior courts which do not have the power to issue a summons in relation to proceedings before it27. As Coroners do have a limited power to summons, it is unclear whether or not this provision applies. In the event that it does, the summons must generally be served at least seven days before the person is required28 and there are strict rules governing service. The Coroner will need to follow the strict procedures to apply for a summons. That application can be challenged and a summons to compel the production of documents may be set aside, for example, on the basis of public interest immunity in appropriate cases.
42. In the event that any member of HSE staff is served with a High Court or county court summons to attend an inquest, you should contact Legal Adviser’s Office.
43. If an inquest concerns a reportable accident or disease, you should normally attend the inquest. Where medical evidence is likely to be important, you should consider involving a Medical Inspector to advise you on the medical aspects of the investigation.
44. The inquest is an inquisitorial (rather than adversarial) process. However, witnesses are required to be ‘sworn in’ in the same way as in any other court of law. No witness is obliged to answer any question that tends to incriminate him/herself and, where a witness has been asked such a question, the Coroner will inform the witness that s/he may refuse to answer .
45. Before attending the inquest, you should carefully consider what papers to bring with you. It is advisable to maintain regular contact with the Coroner following the death. However, if the Coroner has not indicated what material s/he would like you to provide, you should normally, in the first instance, offer to prepare a factual report, setting out the circumstances of the death and listing the witnesses who have given statements to HSE (see The Coroner and HSE).
46. Should the Coroner invite you to sit on the bench with him/her as an assessor, you should decline. While HSE appreciates the wish for a technical assessor, this practice could raise questions regarding the role of the inspector, especially if there were subsequent criminal proceedings30. In general, where an inspector has first hand knowledge of, or expertise in, the matter under consideration, s/he is likely to be of equal assistance if called as a witness.
47. You should attend the inquest whether or not you are required to give formal evidence. Your role at the inquest is as a ‘properly interested person’ as defined by rule 20(1) of the Coroners Rules 1984. As an Inspector of Health and Safety31, you are entitled to examine witnesses at the inquest. This entitlement should be exercised with caution. You should primarily listen to the evidence from witnesses in answer to the Coroner’s questions. The witnesses may also be asked questions by legal representatives of the company or firm involved and by the bereaved and injured, as well as any other properly interested parties. A careful record should be kept of questions asked and answers given by witnesses.
48. In many cases, it will not be necessary for you to ask questions. What witnesses say at an inquest is not admissible evidence as to the truth of that statement in any subsequent criminal proceedings (see below). You will often have taken a statement from them or interviewed them under caution. In general, any questions you ask should be for the purpose of clarification or to provide additional context to the Coroner. If a prosecution for health and safety offences is likely to follow the inquest, inspectors should seek advice from Legal Adviser’s Office before planning to question witnesses at an inquest. Where necessary, legal representation may be arranged.
49. If there is a serious discrepancy between a witness’s evidence during the inquest and a previous written statement, and a prosecution is under consideration, you should seek advice via your legal liaison point. Any evidential inconsistencies will be relevant to the review of the case and may affect the decision to prosecute. Moreover, all inconsistencies between written statements made by potential prosecution witnesses and their evidence at an inquest will be disclosable under the provisions of the Criminal Procedure and Investigations Act 1996 and the Attorney General’s Guidelines on Disclosure (see the sections on Disclosure before 4 April 2005 and Disclosure on or after 4 April 2005).
50. As already mentioned, Coroners’ practices vary widely. However, prior to the inquest date, you will be notified as to whether the Coroner will call you to give formal evidence. You may be informed of this at a pre-inquest hearing (see above). If you are unsure what the Coroner will require, you should contact the Coroner’s Officer prior to the hearing.
51. If you are called to give formal evidence, you will stand in the witness box and the Coroner will ask you to explain your professional role. You will then be expected to answer questions put to you by the Coroner regarding the issues to be determined by the inquest. The extent to which you can provide factual evidence will depend on the time when you attended the scene. You should be careful about offering opinion evidence that is outside your individual expertise.
52. After giving formal evidence, the Coroner will invite the legal representatives present in the court (which may include the representatives of potential defendants in any future health and safety prosecution) to put any relevant questions to you. The family and the jury will then be given an opportunity to ask questions. These are likely to be by way of clarification of the circumstances or technical issues.
53. You must always bear in mind the purpose of the inquest and sensibly refrain from expressing your opinion in relation to any breach of the relevant statutory provisions. It is, however, part of your function at the inquest to refer the Coroner to material that is relevant to the case. This may include:
54. The Coroner will sum up before the jury retires to consider its verdict.
55. Evidence which the Coroner considers unlikely to be disputed may be admitted in documentary form under Rule 37 and will be read aloud at the inquest. This saves time at the inquest and avoids the need for witnesses whose evidence is uncontroversial to attend in person. The fact that a witness is unable to attend the inquest does not allow the Coroner to admit the document into evidence if it is likely to be disputed32.
56. Before admitting evidence under Rule 37, the Coroner will announce details of the document, together with the right of properly interested persons (which would include an HSE inspector) to object and their entitlement to see a copy of the document33. Where a properly interested person objects, the witness has to be called34.
57. The courts have disapproved of attempts to admit all witness evidence without giving interested persons a proper opportunity to consider whether to object. In R v Avon Coroner, ex parte Bentley35, the court found that Rule 37 had been breached because statements from witnesses that were relevant to key issues were read by a police officer when there was no reason to prevent those witnesses from giving live evidence. The case was concerned with an extreme situation where, in the absence of the limited form of disclosure suggested by the court, the properly interested persons would have been ignorant of “the most basic facts” and unable to make an informed decision on whether to object to the witness evidence being read. The examples given in Bentley were the post mortem report and toxicological report. However, the court acknowledged that, in some cases, there will be less need for advance disclosure, or that advance disclosure need not be so extensive.
58. The court in Bentley also confirmed the decision in R v HM Coroner for Lincolnshire, ex parte Annette Hay36 that there is no general rule in favour of pre-inquest disclosure, as the requirements of fairness will vary from case to case.
59. If documentary evidence from the HSE investigation is being considered for disclosure pursuant to Rule 37, you should discuss with the Coroner whether it is likely to be controversial and/or whether disclosure may be prejudicial to the investigation or any subsequent prosecution. Some of the documentary material, for example, whilst relevant to a potential prosecution, might have no part within inquest proceedings and need not be used. See also [The Coroner and HSE SI308] on disclosure of information to, and by, the Coroner.
60. As the inquest is usually held before any prosecution for health and safety offences, evidence given at the inquest will be relevant to the review and preparation of the case and should always be considered in detail before proceedings are begun.
61. Records of evidence given before an inquest37 are not in themselves admissible in subsequent criminal or civil proceedings as evidence of the truth of a witness’s evidence at the inquest38. However, such records may reveal inconsistencies that could affect the decision to prosecute or point to the need for further enquiries.
62. The Coroner is under a duty to take notes of evidence adduced at the inquest39 and is also obliged to provide a copy of those notes to any properly interested person who requests them40. As with obtaining a court transcript, Coroners will charge for copies of their notes. It may be that the Coroner’s notes are admissible as proof of the fact that words contained in the notes were said by the witness at the inquest, but not as evidence of the truth of what was said41. Should you consider it necessary to your case to use the Coroner’s notes in this way, you should contact Legal Adviser’s Office for further advice.
63. As stated above, an inquest verdict must not be framed in such a way as to appear to determine any question of criminal liability on the part of a named party or civil liability42. The following are examples of the type of verdicts that might be returned:
64. Although juries commonly return either a verdict of accidental death or a verdict of misadventure, there is no material difference between the two43. The return of an open verdict is appropriate where the evidence did not fully or further disclose the means whereby the cause of death arose.
65. In HSE cases, the Coroner will often direct the jury to consider a limited range of verdicts. The most common verdicts returned in these cases are ‘Accident’ and ‘Industrial disease’. The verdict is reached ‘on the balance of probabilities’, although you should be aware of the higher, criminal standard of proof (i.e. beyond reasonable doubt) required to find a verdict of ‘Unlawful killing’ or ‘Suicide’. In order for there to be neglect, there has to have been a distinct opportunity to offer or provide relevant care (be that nourishment, liquids, medical attention, shelter or warmth) which was not provided and which directly led to the death. If the timescale between the identified need and the death is too short, there will have been no neglect. Neglect can be a freestanding verdict or the jury may find that neglect contributed to, or aggravated, the death44.
66. Increasingly, as an alternative to the traditional ‘short-form’ verdict, which is limited in nature, Coroners are making use of ‘narrative’ verdicts. A narrative verdict is a factual account of the findings of the inquest and may or may not refer to the terms given above45. The narrative may be answers to a set of questions posed by the Coroner to him/herself or the jury.
67. Coroners have a wide discretion in determining the scope of, and conducting, their inquiry. However, use of that discretion is subject to the principles of public law.
68. Coroners are obliged to use their powers and functions lawfully and for the purposes for which the powers were created. They must take into account all the factors they are under a duty to consider, and must not exercise their discretion on the basis of irrelevant factors. Any decision must be procedurally fair and impartial, and must be a response to each case based on its merits. Coroners must consult where the law requires it, such as when deciding whether to admit documents under Rule 37 (see above). Any decision must be reasonable46 so as to avoid a perverse decision. Appeals against decisions made by Coroners during the inquest process are made by seeking a judicial review of the decision in the High Court.
69. As a public authority, the Coroner is also obliged to act in a way which is compatible with the European Convention on Human Rights, including the right under Article 6 to a fair trial in any criminal proceedings that might follow the inquest. The Memorandum of Understanding with the Coroners’ Society (see [The Coroner and HSE SI309]) seeks to limit the potential for prejudice to any such proceedings.
70. You should note that applications for costs are not made in the Coroner’s court.
71. Under Rule 43 of the Coroners Rules 198447, the Coroner may announce at the inquest that s/he intends to make a report (for example, to HSE) with recommendations for action.
72. Where a Coroner is holding an inquest, s/he may report the circumstances to a person whom s/he believes may have power to take action if:
73. Provided the evidence gives rise to the concern, such a ‘Rule 43 report’ can relate to issues that are peripheral to the inquest, and the deaths the report aims to prevent need not be similar to the death that formed the subject of the inquest48. A report may generally not be made until all the evidence has been heard49.
74. A Coroner who intends to make a report should normally announce the intention before the end of the inquest, although failure to do so will not prevent him/her from subsequently making a report50.
75. The Rules do not specify the information that Coroners must include in a report. However, guidance to Coroners51 states that they should take care not to draft reports in a way that might prejudice related legal proceedings or apportion blame.
76. The Coroner must send a copy of any Rule 43 report to the Lord Chancellor (who may publish the report or a summary of it52) and properly interested persons. Both the Coroner and the Lord Chancellor may also send a copy of the report to any person who, in their opinion, may find it useful or of interest53 (such as other regulatory authorities).
77. Although a person who is sent a report by the Coroner under Rule 43 is not under an obligation to implement any specific recommendations, a written response must be given to the Coroner within 56 days54. The response must contain either:
78. The Coroner has a discretion to extend the deadline for giving a response, even where the application for an extension of time is made after the initial 56 day period for compliance has expired55.
79. On receiving a response, the Coroner must send a copy of it to the Lord Chancellor56. Unless the Coroner decides that the response should not be released in full (see below), s/he must also send a copy to the properly interested persons (including the bereaved family). As with the report itself, the Coroner may send a copy of the response to any other person whom s/he believes may find it useful or of interest.
80. In responding to a report, a person may make written representations to the Coroner about the release of his/her response to the interested persons and others and its publication (but not about sharing the response with the Lord Chancellor). Such representations might be made where the response contains confidential or sensitive information, or where disclosure of the response might have a prejudicial effect on an ongoing investigation or any current or potential legal proceedings. As a result, the Coroner may decide that the response should not be released or published in full, but in this situation s/he must prepare a summary of the response to be released and published instead57. The Coroner will provide the Lord Chancellor with a full copy of the response in addition to the summary.
81. Subject to the Coroner’s decision on release and/or publication of the response, the Lord Chancellor may publish the response and send a copy to anyone who may find it useful or of interest.
82. The Coroner cannot impose a sanction on a person who fails to respond to a Rule 43 report, but may report the failure to the Lord Chancellor.
83. If you receive recommendations for action from a Coroner, you should immediately inform your line manager and the relevant Head of Operations, who will normally approve HSE’s response. Coroners’ reports will usually be received following inquests in which HSE has been involved. However, this may not always be the case.
84. Where appropriate, you should contact the relevant Sector and/or Policy Group for assistance. You may seek advice from your legal liaison point (such as FOD Legal and Enforcement) and Legal Adviser’s Office if required. Points you will wish to consider before responding include the following:
85. In all cases, a written response must be completed within the required period of 8 weeks, beginning with the day on which the report was sent. There may be occasions on which it is not possible to respond fully by this date, for example, where significant policy work is required58. In such a situation, you should send an application for an extension of time to the Coroner, setting out your reasons for the request. The length of any extension is at the discretion of the Coroner.
86. Where a response is required and HSE’s investigation is not yet complete, or if enforcement action is proposed but has not yet been instigated or concluded, the response may explain that the matter is still ongoing and a more substantial reply will follow once a decision on enforcement action has been taken or such action has been completed. However, you should aim to respond as fully as possible without compromising the ongoing investigation; it may be possible to address the Coroner’s concerns in general terms, so as to avoid such a risk of prejudice.
87. You should bear in mind that HSE’s response will normally be disclosed to each interested party to the inquest (including the bereaved family), and to any other person whom the Coroner believes may find it useful or of interest. As stated above, HSE may make written representations to the Coroner regarding the disclosure of its response and such representations should be sent no later than the response itself. The Coroner has a discretion as to whether to accept the representations and wherever possible, therefore, the response should be drafted as a fully open document. Where this is not possible and the Coroner indicates that s/he does not intend to accept HSE’s representations, you should immediately contact your legal liaison point or Legal Adviser’s Office for advice.
88. Where HSE is to take action as a result of the Coroner’s report, you should explain what HSE will do and give approximate timescales.
89. However, as explained above, a person in receipt of a Rule 43 report may decide not to take action as a result of the Coroner’s recommendations. Where such a decision has been reached, the written response should explain why and set out HSE’s reasons in full.
90. In all cases, a copy of the response as sent should be recorded on TRIM in folder 4.9.174. The document title should include “Rule 43 report – final response – inquest touching on the death of [name]”.
91. The Ministry of Justice has published a draft Coroners Bill, which sets out proposed reforms to the current system. The Bill has been included in the Queen’s speech and presented to Parliament.