Learn lessons, save lives
Tracking tragedies for evidence-based prevention
A campaign to reform coronial law for learning and prevention.
Why is reform needed?
Unnatural deaths are referred to coroners in England and Wales, but after investigation, nothing is done to learn from these deaths.
Currently, siloed systems exist and data is not captured, shared or used, missing opportunities for learning, prevention and progress. The Coroner Service is in crisis, change is needed now to save lives.
Reforms will ensure:
- Bereaved people know their loved one’s death will inform the prevention of further harm.
- The Coroner Service, Medical Examiner System and Death Review panels will contribute to measurable safety improvements.
- Policymakers, practitioners and the public will have access to real-time, transparent insights and evidence to inform decision making.
- Ultimately save lives – fewer preventable deaths!
What are we calling for?
We’re calling on the UK Government to reform the Coroners and Justice Act 2009 and The Coroners (Investigations) Regulations 2013 to:
Statutory national database of all inquests and PFDs
Amend the law to add “collect, analyse and share” as coronial duties so that information obtained during ALL investigations can be used for learning, enabling transparent, open and real-time publication of accurate statistics.
Independent research prevention unit
Through statutory and sustainable, the independent unit will routinely analyse the national database, providing transparent and open tools, including dashboards and surveillance systems using evidence-based methods.
Sharing and linkage between systems and nations
Data from the statutory Medical Examiner system, safeguarding reviews, e.g. Domestic Homicide Reviews (DHRs), and across the UK nations, from England, Wales, Scotland and Northern Ireland, must be linkable to enable complete reporting and learning across borders.
What does success look like?
Centralised and uniform data collection
Standardised data that enables sharing, analysis and learning across systems and jurisdictions.
Open, transparent, and real-time reporting and follow-up
Enforcing collection and responses ensure accountability and completeness.
Resources and capacity building
Sustainable funding ensures infrastructure and expertise can be maintained, ultimately reducing the burden on the Coroner Service and saving lives.
Join the movement, make it count.
We believe that one preventable death is one too many. But if we don’t track, we can’t measure progress. Together, we can save lives, ensure tragedies are not ignored, and turn them into lasting change.
