Coroners reform and the use of Rule 43

Following consultation on changes to Coroners Rules in 2007-2008, Parliament enacted the changes in a Statutory Instrument (SI) in July 2008. These changes may have some impact on organisations responsible for water-based activities and this Briefing Note highlights the relevant changes.

Coroners Reports

The new Rules extend the powers of Coroners in making reports, recommending actions that might prevent future deaths, and publicising the findings and responses to those reports. Previously Coroners could only make reports that might prevent deaths in 'similar circumstances' and could not take account of the wider context or that recommended safeguards might themselves present a risk in alternative circumstances. The wider remit to make reports has been extended to make recommendations that might prevent 'any' future deaths and not just in 'similar circumstances'.

The previous Rules also required a Coroner to announce his intention to make a report prior to the Inquest. The change allows Coroners to make reports without having previously announced the intention to do so, allowing them the flexibility to take account of the evidence presented on the day. In addition, the new Rules allow Coroners to produce reports taking account of appropriate information from previous Inquests as well as from Inquests that have been adjourned or not resumed.

The allowance for a better system of Collective reporting will also improve the ability of Coroners to consider a bigger picture and make appropriate recommendations to prevent any future deaths.


Prior to the SI, there was no statutory duty for the individual or organisation who was the subject of a report to respond. The Act formalises the requirement for a response to be made within 56 days. Since most reports would be made to businesses or organisations such as Sports Governing bodies, then it should be possible to respond within this timescale. However, for smaller organisations, perhaps reliant entirely on volunteers or for individuals it is at the discretion of the Coroner to extend this period. NWSF would advise in such circumstances that anyone receiving a Coroners report should immediately acknowledge receipt and confirm in writing a commitment to respond within the timescale or if necessary formally request a reasonable extension (setting out the reasons why).

Responses to a Coroners Report must be in writing. It is important to note that a respondent is not obliged to act on the recommendations of the report but if they are not then the response must clearly set out the reasons for not implementing the recommendations. The most likely reasons for not doing so are that the recommendations would be likely to create further risks in different circumstances. It is likely that organisations in particular would be the appropriate experts in their respective fields and should respond positively and effectively to any report made. This allows the Coroner to make future recommendations in a more informed way. Organisations should take careful note however that should subsequent incidents occur that might have been prevented if the report had been followed this could impact on any subsequent proceedings.

Sharing and Publishing

The objective of Coroners Reports has always been to prevent future deaths. The Rules however limited and even restricted the making of reports to a very limited audience (properly interested parties) thus reducing their effectiveness. The Act allows for wider dissemination of Reports including:

  • Between Coroners
  • Interested parties
  • Other stakeholders (e.g. regulatory bodies such as HSE)
  • Lord Chancellor

The main responsibility for publishing the Reports Nationally (England & Wales) would rest with the Lord Chancellor. Any published report could include both the Report and any Responses. It is likely however, that only Summaries of both would be published rather than full copies but there is to option to publish relevant items in full.


It should be carefully noted that the Prime Objective of the changes in Coroners Rules is preventing future deaths.


This page is currently under review, as such please note that this page may contain information that is dated.
October 2014