Responses to prevention of future death reports
Paragraph 7 of Schedule 5, Coroners and Justice Act 2009, provides coroners with the duty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths. When a report is received by the Royal College of Anaesthetists or the Association of Anaesthetists, SALG develops the response and works to implement any actions.
Pamela Anne Marking
We extend our deepest sympathies to the family of Mrs Marking, whose sad death in February 2024 was the subject of a coroner's inquest that concluded in December 2024. We received a prevention of future deaths report that raised concerns relating to the practice of rapid sequence induction (RSI). Full details of the report are available on the coroner's website: https://www.judiciary.uk/prevention-of-future-death-reports/pamela-marking-prevention-of-future-deaths-report/
Our joint response is available to read below, which highlights the current guidance available and steps that are underway to update it: