Learn lessons, save lives
Tracking tragedies for death 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 systematically 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.
- Preventable deaths won’t be repeated, lives will be saved – 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:
Build a national statutory database for learning from deaths
Right now, when people die from avoidable deaths, the lessons are buried.
So we’re calling for a national database to collect and publish information from coroners, medical examiners, and death reviews. We need to learn lessons from preventable deaths to save lives.
Create an independent expert team to turn lessons into prevention
Establish an independent, expert-led research unit to study preventable deaths and make sure patterns are spotted. With the right data and tools, this team could stop dangerous systems or repeated failures from continuing to cause harm.
Link the data to connect the dots across the UK
At the moment, critical information about deaths sits in silos across different agencies and even other nations. That means warning signs are missed. We need to join up information between the Coroner Service, the NHS, safeguarding bodies, and devolved nations to enable swift, actionable learning.
These three changes will create a system that sees patterns faster so actions can be taken sooner to save lives. Let’s build a system that learns and saves lives.
Letter sent to the Ministry of Justice
Written by the Justice Select Committee in May 2024
Following the follow-up inquiry to the Coroner Service
“I would like to comment on the use of coronial data as a tool to analyse and understand preventable deaths and, ultimately, stop more of them happening. Dr Richards’ “Preventable Deaths Tracker” website has shown what is possible for a relatively small cost. It seems extraordinary that such an important national service is reliant on the initiative and energy of a single academic working without reliable funding. The Tracker should be placed on a secure footing and used as the basis for further work – whether this means it is brought within Government or central funding is found for it, should be the subject of further consideration.”
“I am also very concerned that the UK is falling behind other jurisdictions in the efficient and effective use of coronial data. The Government should scope the creation and maintenance of a Coronial Information Service, similar to that already provided in Australia and New Zealand.”
Sir Robert Neill KC (Hon)
MP for Bromley and Chislehurst from 2006 to 2024
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.
Campaign milestones
