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Risks or vulnerabilities can arise from any death and part of any professional’s role is to be alert to remediating them as part of patient safety. This chapter will look at how to identify these risks. It will also consider what to do when criticism occurs, and how to remediate to allow for a satisfactory or moderated outcome.
This chapter will briefly describe the outcomes of a coroner’s inquest: the findings available to the coroner, and the types of concerns that they can express. It will also explain Regulation 28 (Prevention of Future Death) reports.
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