Four years of published coroners’ Section 28 reports in England and Wales


By Dr Minh Alexander NHS whistleblower and former consultant psychiatrist 24 August 2017

This is a paper which reports on four years of data on coroners’ special warning reports published by the Chief Coroner, up to 31 July 2017, and which shares a database on the four years of Section 28 reports collated from the Chief Coroner’s website.

This is the full report with links to supporting data:

Four years of published coroners_ Section 28 reports to prevent future deaths in England and Wales

The summary of the report is as follows:


In the recent years of austerity, the government has run an explicitly anti-red tape programme, purportedly business friendly but openly hostile to ‘Health and Safety’ regulations.

This paper shares a database collated from four years of coroners’ Section 28 warning reports about public safety that have been published by the chief coroner, and a broad initial report about the data.

Although it is positive that Section 28 reports have been published in recent years, I collated this data because the chief coroners’ website is not searchable and does not give the public access sufficient, meaningful access to Section 28 reports. Patterns are further obscured by inconsistent indexing of cases. Some notable instances of miscategorisation of important cases were found (for example suicides, police related deaths, deaths in custody, deaths of armed forces personnel).

Questions also arise about the completeness of the data released. It is very likely that a number of reports have not been published.

Of the data that exists:


  • At least 57.2 % (987 of 1725) of published Section 28 reports related to poor NHS care and hazards.


  • Seventy Section 28 reports related to deaths in the custody of the State


  • 350 Section 28 reports related to self inflicted deaths, whether through misadventure or by suicide.


  • 60 Section 28 reports were about deaths where there had been neglect, including eight deaths in State custody.


  • The majority of the ‘neglect cases’ were accounted for by the NHS.


There were no published responses at all to 62% (1070 of 1725) of Section 28 reports by organisations and persons who had been sent them for action to prevent future deaths. Moreover, no explanation is provided for this by the chief coroner’s office.

The paucity of published responses is unexpected because past government records showed the vast majority of organisations previously responded to Rule 43 reports, which were the predecessor to Section 28 reports. Clarification is needed on whether response rates have deteriorated and or whether the Chief Coroner is choosing not to publish responses.

The lack of published responses to coroners’ warnings raises questions about whether the audit cycle is being closed and therefore the effectiveness of public protection. The Grenfell fire being the most painful illustration possible of the consequences of such failure.

Relevant to fire safety, there were twenty published Section 28 reports in the last four years relating to fire safety, including recommendations for instalment of fire sprinklers and alarms in social housing, and the need to investigate the use of flammable insulating material in Hotpoint fridge freezers which can act as an accelerant.

In relation to NHS cases, notwithstanding the limitations of the coroners’ data, a number of recurring themes are evident, raising questions about organisational learning. Coroners highlighted a lack of resources in a number of important cases, some acute.

Of great concern to public safety, it is also clear that coroners have been seriously concerned for several years about deteriorating ambulance responses and the role of related call handling and diversion services. Ambulance delays have cost lives and put the public at risk.

The effectiveness of the Department of Health’s response to coroners’ concerns is in question. The credibility of CQC’s ratings on ambulance trusts is also challenged by the concerns that coroners have been repeatedly flagging. CQC’s recent rating of an ambulance trust as ‘Outstanding’ is especially questionable when all are clearly operating in severely challenging conditions.

These concerns are underlined by the fact that Coroner’s Section 28 reports represent only the tip of a safety iceberg.

Currently, there is no evidence of a systematic government approach to learning from the Section 28 reports. There is no published evidence of central analysis.

I have written to ask the Chief Coroner about:

  • How many of the Section 28 reports issued so far have been published
  • Missing responses from recipients of Section 28 reports
  • Any government analysis that is taking place
  • What happens if coroners are dissatisfied by Section 28 responses
  • Possible improvements to the website for greater transparency.


The Department of Health, NHS regulators and other oversight bodies will be asked about their handling of Section 28 reports.”

I should be very grateful and interested to hear from anyone who is aware of coroners’ Section 28 reports that have been issued but have not been published.

Please contact me via the contact page of this site.

Many thanks.

Minh Alexander



There were 27 and not 20 Section reports on fire related deaths published by the Chief Coroner up to 31 July 2017.






‘Who is the Chief Coroner?’



5 thoughts on “Four years of published coroners’ Section 28 reports in England and Wales

  1. Presumably these are old Rule 43 Letters? ……….which many trusts used to prepare for the next inquest but learning was still in ‘Nice round figures’ aka ooooooooooooooooooooooooo


    1. Hi Dee. Section 28 reports are exactly like Rule reports because they aren’t discretionary – coroners are now under a duty. And the scope is greater. Coroners should in theory issue a Section 28 report in relation to all relevant risks that they find, and are no longer confined to risks that related just to the death in question. This is an interesting take on it by Mills and Reeve, with an institutional perspective, naturally:


  2. This rings a bell for me strongly at the moment, as mum has recently died, and I could see it was from a drug called Tamoxifen (she was 92), she deteriorated rapidly (four weeks) from walking about unaided to becoming a bed ridden skeleton, I detailed it all to the locol coroner as was unhappy with the main cause of death being appended to fragility from old age, but could get nothing done, so as usual no lessons learned, cover up rules,so likely despite the available stats, there is so much more unchecked/recorded. It had been requested that this drug be stopped after two weeks, but this did not happen due to lack of communication. I hoped to make the point that the use of strong drugs for the elderly should be reviewed. Peggy


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