PPO.63 Patient safety in the nhs: the role of the coroner rule 43 in improving maternal safety

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This review looks at the duty of the Coroner as an external independent judiciary officer to promote patient safety in maternal heath, and highlights the Coroner’s Rule 43.


- The role of the Coroner is increasingly improving maternal health, both by investigating a death, and to promote proactive patient safety by making recommendations to prevent a future death (Coroners Rule 43 amended).


The Ministry of Justice 9th Coroners Rule 43 Report for England and Wales (June 2013) showed between 1/10/ 2012–31/03/2013 -


The UK CEMACE Report (2006–2008) highlighted significant sub-standard patient care, thus more cases will be referred to the Coroner.


The Coroner continues to play an important role to improve safety in maternal health. With the record increase in Coroner’s Rule 43 being issued, in the current medico-legal climate, patient safety remains of paramount importance.

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