Preventing future deaths
The Coroner has a legal power and duty to write a report following an inquest if it appears there is a risk of other deaths occurring in similar circumstances. This is known as a “Regulation 28 Report” or “Prevention of Future Death Report'
The report is sent to the people or organisations who are in a position to take action to reduce this risk. They then must reply within 56 days to say what action they plan to take.
The Coroner will send a copy of the report and the replies received to the family. The names of the people and organisations receiving the report (but no details about your relative) are posted on the Ministry of Justice website, so it becomes a matter of public record that they have had to answer a report.