Delivering learning from deaths
Tracking tragedies to save lives
A campaign to reform coronial law for learning and prevention.
Why is reform needed?
Thousands of lessons emerge from inquests and investigations every year, but they’re buried, often forgotten, dismissed, or simply not implemented.
Families want lessons to be learnt, but the ‘system’ relies on those grieving to campaign for change, often spending decades fighting for justice and legislative change.
As a nation, we spend significant public funds and place enormous pressure on public services to investigate deaths, yet we fail to capitalise on that investment.
Other countries, like Australia and Canada, have established systems to integrate lessons from deaths into public health, policy, and practice; the UK should do the same.
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:
Deliver a National Learning from Deaths Strategy
Many processes and silos have been created, but it’s unclear how the government, public bodies & society actually learns from deaths.
Commissioning an independent review would identify what systems exist, what information they currently use, and establish a national plan for a safer, effective and responsive approach to preventing future deaths.
Establish a National Statutory Database of ALL inquests
When people die from avoidable deaths, the lessons are buried in Coroner’s Offices.
Less than two per cent of all inquests (~450 deaths/year) have a Prevention of Future Deaths report written. So we’re calling for a national database to collect and publish information from all inquests, ~36,000 a year.
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 the information between the Coroner Service, medical examiners, the NHS, safeguarding bodies, and devolved nations to enable swift, actionable learning. We need an experienced, interdisciplinary, and independent research unit.
These three changes will create a system that spots patterns faster, so we can act 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 without tracking, we can’t measure progress.
Together, we can save lives, ensure tragedies are not ignored, and turn them into lasting change.
Campaign milestones
