CQC recognises HM Coroners as important external stakeholders for us. In particular:
- Coronial investigations including final inquest hearings and regulation 28 preventing deaths reports. These can yield extremely valuable evidence and information we can use to discharge our regulatory functions. These are to monitor, inspect, and undertake civil and criminal enforcement.
- We are expected, and sometimes required, to assist HM Coroners with:
- investigations
- inquests
- responding to Regulation 28 Preventing Future Deaths Reports.
We have agreed a memorandum of understanding with the Coroners Society of England and Wales (‘MoU’). This supports consistently robust, effective and efficient cooperation with Coroners,
We have developed, and improved, internal processes and operational guidance products to:
- support the operation of that MoU
- ensure robust, appropriate and systematic handling of coronial correspondence, including Regulation 28 reports.
We use a dedicated email inbox to receive and monitor all coronial correspondence: CQCInquestsandCoroners1@cqc.org.uk .
How CQC deals with Regulation 28 Preventing Future Deaths Reports
Regulation 28 reports may be addressed to us requiring formal response, or sent for information. We use information or concerns contained in any Regulation 28 report about the provision of care by a registered provider.
- The operational team responsible will consider the contents as part of our monitoring of that service. This will inform proper exercise of our functions on a case-by-case basis. This could include making informal enquiries and undertaking a formal assessment of the service. The findings from a formal assessment will inform and may result in a change to the rating for that provider.
- Our regulatory actions may also include civil or criminal enforcement. We would take such action where appropriate and in line with our enforcement policy and enforcement decision tree.
Continuing improvement: inquests improvement project
This multi-disciplinary project is ongoing and is part of our commitment to continual learning and improvement.
It aims to make wide-ranging improvements in how we handle all coronial correspondence, including Regulation 28 reports. Key workstreams in this project are:
- External transparency: Messaging on this website and through engagement to clarify what we do with information provided by coroners
- Regional and national trend analysis: There is no centrally developed thematic analysis of trends and themes from Regulation 28 reports. So we are considering how to improve our qualitative and quantitative analysis to inform how we discharge our regulatory functions.
- Operational guidance and relationship building: We are analysing our internal process and guidance. This is to improve and ensure:
- reliable handling of coroner correspondence
- engagement with coronial investigations and Regulation 28 reports.
We are also considering this work as part of our new ways of working under our new assessment framework.