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.

We received a prevention of future deaths report following the conclusion of the coroner's inquest in October 2023 about the sad death of Ms Green. The report, which is available here, highlighted a concern that “some anaesthetists are unlikely to be aware that endoscopists may not necessarily know that a perforation has occurred during the procedure, and the anaesthetists will not have the potential for pneumocephalus in their thinking.”

Our joint response is available to read below. 

We received a prevention of future deaths report following the conclusion of the coroner's inquest in September 2025 regarding the sad death of Mr King. The report, published on the coroner's website, raised concerns about the process and documentation of discussions leading to informed consent for nasogastric tube insertion prior to an emergency laparotomy for bowel obstruction. 

Our joint response is available to read below. 

We received a prevention of future deaths report following the conclusion of the coroner's inquest into the sad death of Mrs Marking in February 2024. The report, which is available on the coroner's website, highlights concerns relating to the practice of rapid sequence induction (RSI). 

Our joint response is available to read below, which highlights the current guidance available and steps that are underway to update it:  

We received a prevention of future deaths report following the conclusion of the coroner's inquest in October 2023 about the sad death of Mr Frame. The report, which is available on the coroner's website, highlighted a concern regarding the "absence of a national policy on the placement of central venous catheters (CVCs)". 

Our joint response is available to read below.