The Coroners (Investigations) Regulations 2013

Report on action to prevent other deaths

28.—(1) This regulation applies where a coroner is under a duty under paragraph 7(1) of Schedule 5 to make a report to prevent other deaths.

(2) In this regulation, a reference to “a report” means a report to prevent other deaths made by the coroner.

(3) A report may not be made until the coroner has considered all the documents, evidence and information that in the opinion of the coroner are relevant to the investigation.

(4) The coroner—

(a) must send a copy of the report to the Chief Coroner and every interested person who in the coroner’s opinion should receive it;

(b) must send a copy of the report to the appropriate Local Safeguarding Children Board (which has the same meaning as in regulation 24(3)) where the coroner believes the deceased was under the age of 18; and

(c) may send a copy of the report to any other person who the coroner believes may find it useful or of interest.

(5) On receipt of a report the Chief Coroner may—

(a) publish a copy of the report, or a summary of it, in such manner as the Chief Coroner thinks fit; and

(b) send a copy of the report to any person who the Chief Coroner believes may find it useful or of interest.