Intended for healthcare professionals

News

Deaths from medicines: lessons from coroners’ reports are too easily lost, review finds

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4322 (Published 12 October 2018) Cite this as: BMJ 2018;363:k4322

Re: Deaths from medicines: lessons from coroners’ reports are too easily lost, review finds

I agree with Robin Ferner and colleagues. It is vital that Regulation 28 reports from Coroners are in the public domain. When writing this BMJ paper (1), we wished to cite a Regulation 28 report (2), but these are not always freely accessible as is the case in other countries. The Gloucester coroner kindly supplied a copy of the report - from the inquest of Elizabeth Jill Ryder (who died 9/10/14) (2) - but it is not possible to find this in any form of searchable database (3). For our BMJ paper, we cited a similar Australian case instead (4), which only took a few minutes on Google to find. Is it not time for all Regulation 28 reports to be published via the Chief Coroner's website? It is clearly in the public interest that there is as much learning from such tragic cases as possible in order to improve patient care.

1) https://www.bmj.com/content/363/bmj.k3252.long

2) https://twitter.com/djnicholl/status/1053549369545371648

3) http://ww3.gloucestershire.gov.uk/coronerinquest/PersonSearch.aspx

4) http://www.coroners.justice.nsw.gov.au/Documents/burns%20findings%209%20...

Competing interests: No competing interests

20 October 2018
David J Nicholl
Consultant Neurologist
Clinical Lead for Neurology
City Hospital, Birmingham, B18 7QH