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, there is no systematic capture and use of this information to learn from these deaths.
Currently, siloed systems exist and information 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
Amend the law so that coronial duties include collecting and sharing information obtained during ALL investigations, which can be used for immediate learning, enabling transparent, open, and real-time publication of accurate statistics.
Independent research prevention unit
Establish an independent and appropriately skilled research unit to routinely analyse the national database, providing transparent and open tools, including dashboards and surveillance systems using evidence-based methods.
Sharing and linkage between systems
Data from the statutory Medical Examiner system, safeguarding reviews, and UK nations 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, where progress is measured in real-time.
Openness and transparency
Enforcing the collection and reporting of responses in realt-time ensures accountability and completeness.
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.
