Recurring concern
Failure to reliably report deaths to coroners
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Request correctionFirst reported 1 Jul 2014•Latest report 25 Nov 2025
What this concern includes
Includes failures in the process for recognising, deciding, documenting and making required or appropriate reports of deaths to coroners, including inappropriate advice about whether to call the Coroner and late, omitted or potentially improper reporting of neonatal or child deaths.
Not included
- Excludes post-mortem, autopsy, inquest and death-investigation deficiencies after a death has been appropriately reported to the Coroner.
- Excludes failures in determining or recording the cause of death where the coroner-reporting decision itself is not deficient.
- Excludes generic death notification or verification-record errors that do not affect whether a death is appropriately reported to the Coroner.
- Excludes police, organ-donation or other judicial decisions unless they directly concern reporting a death to the Coroner.
- Reports
- 9
- Individual concerns
- 11
- Date range
- 2014–2025
- Stated actions
- 3
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure to raise possible anaphylaxis deaths with the senior coroner at the earliest opportunity
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Suspected anaphylaxis should be raised with the Coroner’s officer by the referring medical practitioner or police before the pathologist is contacted.
Stated by Royal College of Pathologists
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Concerns raised2
Failure to appropriately refer neonatal deaths to the coroner
Failure of neonatologists to appropriately report deaths to the coroner
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Reiterate to neonatal and Trust leadership staff that concerns about a death should prompt referral to the Coroner.
Stated by Chelsea and Westminster Hospital NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The response addresses only concerns within NHS England’s national policy and programme remit, excluding hospital-specific matters.
Stated by NHS England
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Position
Chelsea and Westminster NHS Foundation Trust should respond to concerns specific to its hospital and care.
Stated by NHS England -
Position
Existing statutory Medical Examiner reviews, referral criteria and multidisciplinary reviews are considered sufficient to ensure neonatal deaths are appropriately referred.
Stated by Chelsea and Westminster Hospital NHS Foundation Trust
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Concerns raised1
Delays in reporting deaths to a Coroner
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Review all deaths through the Medical Examiner Office, including cause-of-death certification, bereaved-family concerns and referrals for further review.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
BHRUT is responsible for responding fully to the concerns, so the Department will not duplicate its response.
Stated by Department of Health and Social Care
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Concerns raised1
Delays in raising suspected anaphylaxis deaths with the Senior Coroner
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Establishing the systems identified by the Coroner falls outside UKHSA’s remit.
Stated by UK Health Security Agency
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Concerns raised1
Under-reporting of eating disorder deaths to the coroner
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Convene a stakeholder round table and publish guidance for medical examiners on investigating eating disorder deaths.
Stated by NHS England
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Concerns raised1
Failure to notify the Coroner of a child death
This report raised 19 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The Trust is responsible for setting out and implementing actions to address the identified maternity-service safety risks.
Stated by Department of Health and Social Care
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Concerns raised2
Failure to provide appropriate advice on calling the Coroner or police
Gap in Out of Hours doctors’ training on reporting deaths to the Coroner
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of automatic coroner referral for deaths of inpatients subject to safeguarding alerts
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to notify the Coroner of a trial patient's death and trial involvement
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026