Re: Deaths from medicines: lessons from coroners’ reports are too easily lost, review finds
Robin Ferner and his colleagues are right to point out the dearth of information on replies that public bodies send to coroners who issue Regulation 28 (erstwhile Rule 43) letters, which by law require a response within 56 days. I have attended many coroners' inquests as an expert witness at which no members of the press were present and no public records of responses to such letters seem to have existed. The BMJ would serve patient safety well if it ran a series of case reports on selected coroners' inquests with important lessons for clinical practice, highlighting the common problems that arise in such cases and possible solutions. Responses to Regulation 28 letters should be in the public domain.
Competing interests: JKA has co-authored many papers with Robin Ferner; he has often appeared as an expert witness at coroners' inquests and written legal reports on adverse drug reactions.