The first annual summary of coroners’ reports into the circumstances around avoidable deaths has highlighted the need for better hospital communication processes.
Since the rules were changed last year, coroners have been able to write detailed reports following inquests that highlighted a risk of more deaths occurring.
Some commentators have warned the reports, by emphasising failures and shortcomings, could put managers at greater risk of actions under the Corporate Manslaughter Act.
Of 207 reports completed between July 2008 and this March, 58 arose from hospital deaths, 19 were classed as mental health related, 19 were associated with community healthcare and emergency services and 11 were linked to drugs and medication.
Other categories included road deaths, care homes, railways and service personnel.
The Ministry of Justice summary report refers to “the need for better communication and procedures within hospitals”.
It also calls for a specialist allergy service and for bags of drugs to be clearly marked.
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