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

Area of Science:

• Public Health
• Legal Medicine
• Medical Law

Background:

• Her Majesty's (H.M.) coroners issue Regulation 28 (Reg. 28) reports to identify and mitigate hazards that could cause future deaths.
• These reports are electronically published by the Chief Coroner in various categories since 2013, including child deaths, alcohol, drugs, and medications (ADM), and railways.

Purpose of the Study:

• To analyze the effectiveness and consistency of the H.M. coroner's Reg. 28 reporting system.
• To identify systemic issues in report generation, addressee responses, and the implementation of remedial actions.

Main Methods:

• Analysis of the most recent 50 Reg. 28 reports from child deaths, ADM, and railways categories.
• Inclusion of an additional sample of neonatal cases.
• Examination of report generation rates, addressee response rates, organizational size impact, and substantive remedial actions.

Main Results:

• Significant variation in Reg. 28 report generation rates across different coroner areas.
• A substantial deficit in addressee responses compared to issued reports.
• Larger organizations are more likely to respond; substantive actions are infrequent, and unexplained sex imbalances exist in reports, particularly for neonates.

Conclusions:

• The Reg. 28 report system exhibits haphazardness in multiple aspects.
• There is significant potential for improvement in the Reg. 28 reporting process to enhance its impact and public support.
• Recommendations are proposed to improve the system's efficiency and effectiveness.