Birkbeck, University of London, UK.
Med Sci Law. 2021 Jul;61(3):186-192. doi: 10.1177/0025802420987431. Epub 2021 Jan 20.
Her Majesty's (H.M.) coroners issue Regulation 28 (Reg. 28) reports following inquests. These reports concern hazards which, if mitigated, might prevent future deaths, and have addressees who are best placed to take remedial actions. Since 2013, the reports and addressees' responses are copied to, and electronically published by, the Chief Coroner in non-exclusive demographic, aetiological or venue categories. Three of those categories were chosen so as to minimise the replication of unique cases - child deaths; alcohol, drugs and medications (ADM); and railways - with the most recent 50 reports in each category. A further ad hoc sample of neonates was taken after a finding in the first of these. The principal findings are: (a) H.M. coroners generate Reg. 28 reports at different rates (including 27 coroner areas with none at all; random variation probability ≈ 10); (b) there is a large deficit of addressees' responses compared with Reg. 28 reports that are issued; (c) addressees from large organisations are more likely to respond than small ones; (d) substantive remedial actions appear in only a further subset of addressees' responses; and (e) there is a sex imbalance in Reg. 28 reports which is least explicable for neonates. It is concluded that the Reg. 28 report system is haphazard in many ways. As the only official publication from H.M. coroners' courts, Reg. 28 reports have a large scope for improvement, which might promote support from bereaved families and the wider public for the process of inquest. Suggestions for process improvement are made.
女王陛下（H.M.）的验尸官根据调查发布第 28 号规定（Reg. 28）报告。这些报告涉及如果减轻，可能会防止未来死亡的危害，并确定了最有能力采取补救措施的对象。自 2013 年以来，报告和对象的回应被首席验尸官以非排他性的人口统计学、病因学或场地类别复制并以电子方式发布。选择了其中三个类别，以尽量减少独特案例的重复——儿童死亡、酒精、药物和药物（ADM）以及铁路——每个类别都包含最近的 50 份报告。在第一个类别中发现后，又对新生儿进行了另一个专门的抽样调查。主要发现是：(a) H.M.验尸官以不同的速度生成第 28 号规定报告（包括 27 个验尸官区域完全没有；随机变异概率≈10）；(b) 与发布的第 28 号规定报告相比，对象的回应存在很大的差距；(c) 来自大组织的对象比小组织的更有可能回应；(d) 实质性的补救措施仅出现在对象回应的进一步子集中；(e) 第 28 号规定报告存在性别不平衡，对新生儿的解释最少。因此，第 28 号规定报告系统在许多方面都是随意的。作为 H.M.验尸官法庭唯一的官方出版物，第 28 号规定报告有很大的改进空间，这可能会促进家属和更广泛的公众对调查过程的支持。提出了改进过程的建议。
