What are we calling for?
We’re calling on the UK Government to deliver a National Learning from Deaths Strategy :
Deliver a Learning from Deaths Strategy
Many processes have been created, but it’s unclear how the government actually learns from deaths.
Commissioning an independent review would identify how systems currently use information and establish recommendations for a safer, effective and responsive approach to preventing future deaths.
Establish a National Statutory Database
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 must learn lessons from preventable deaths to save lives.
Join the dots across the UK
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.
Who else supports this?
The Justice Select Committee
Letter written to the Ministry of Justice when concluding 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.
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If you’ve interacted with or been impacted by the Coroner Service in England and Wales, share your story.
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