Death

The Government is committed to improving transparency and accountability in the state’s response to learning from investigations involving state-related deaths and more widely. To this end, we are actively considering how we can most effectively address concerns about the lack of oversight and monitoring of recommendations and findings from public inquiries, inquests and other investigation processes.

For example, in the context of the recent response to the Grenfell Tower Inquiry Phase 2 report (Grenfell Tower Inquiry Phase 2 Report: Government response (HTML) - GOV.UK), we have undertaken to establish a publicly accessible record of all recommendations made by public inquiries since 2024; we will ensure that this becomes standard practice for all future public inquiry reports; and will consider putting the requirement to maintain such a record on a statutory footing.

In addition, the Ministry of Justice is undertaking a programme of work in light of the Justice Committee’s recent recommendations for the coroner service, including those aimed at better learning from death investigation and other fact-finding processes. This will include further work to improve accessibility to information from coroners’ Prevention of Future Death reports; and to ensure, particularly across government, that lessons from these reports are learned; that learning is disseminated as quickly and widely as possible; and that it is effectively monitored and evaluated. We are also working with the Chief Coroner to identify ways to further improve the transparency and availability of the published reports and accountability for responses to them.