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    How well do Regulation 28 reports serve future public health and safety ?

    Fox, Anthony and Jacobson, Jessica (2021) How well do Regulation 28 reports serve future public health and safety ? Medicine, Science and the Law , ISSN 0025-8024.

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    H.M.Coroners issue Regulation 28 (Reg.28) reports following inquests. These reports concern hazards which, if mitigated, might prevent future deaths and have addressees who are best placed to take remedial actions. Since 2013, the reports and addressees’ responses are copied to, and electronically published by, The Chief Coroner, in non-exclusive demographic, aetiological or venue categories. Three of those categories were chosen so as to minimise the replication of unique cases: child deaths, alcohol drugs and medications (ADM) and railways, with the most recent n = 50 reports in each category. A further ad hoc sample of neonates was taken after a finding in the first of these. The principal findings are: a) H.M. Coroners generate Reg.28 reports at different rates (including 27 Coroners’ Areas with none at all; random variation probability p ≈ 10-6); b) there is a large deficit of addressees’ responses compared with Reg.28 reports that are issued; c) addressees from large organisations are more likely to respond than small ones; d) substantive remedial actions appear in only a further subset of addressees’ responses; and e) there is a gender imbalance in Reg.28 reports which is least explicable for neonates. It is concluded that the Reg.28 report system is haphazard in many ways. As the only official publication from H.M. Coroners’ courts, the role of Reg. 28 reports in preventing further deaths has a large scope for improvement, which might promote support from bereaved families and the wider public for the process of inquest. Suggestions for process improvement are made.


    Item Type: Article
    Keyword(s) / Subject(s): H.M. Coroner, Regulation 28 Report, Decision making, Public health and safety
    School: Birkbeck Faculties and Schools > Faculty of Humanities and Social Sciences > School of Social Sciences
    Research Centres and Institutes: Crime & Justice Policy Research, Institute for
    Depositing User: Jessica Jacobson
    Date Deposited: 15 Feb 2021 10:22
    Last Modified: 02 Aug 2023 18:07


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