How well do Regulation 28 reports serve future public health and safety?
How well do Regulation 28 reports serve future public health and safety?
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DOI：
10.1177/0025802420987431
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发表时间：
2021-01-20
影响因子：
1.5
通讯作者：
Jacobson, Jessica
中科院分区：
文献类型：
--
作者：
Fox, Anthony W.;Jacobson, Jessica
女王陛下（H.M.）死因裁判官在研讯后发出第28条（Reg.28）报告。这些报告所涉及的危险，如果得到缓解，可能会防止未来的死亡，并有最适合采取补救行动的收件人。自2013年以来，报告和收件人的答复被复制给首席死因裁判官，并由首席死因裁判官以电子方式发布，不限于人口统计学、病因学或地点类别。其中三个类别被选择，以尽量减少重复的独特情况-儿童死亡;酒精，毒品和药物（ADM）;和铁路-与最近的50个报告在每个类别。在第一次发现后，对新生儿进行了进一步的特别采样。主要发现是：（a）H.M.死因裁判官以不同的速度生成规例第28条报告（包括27个死因裁判官区，但没有任何死因裁判官区;随机变异概率p约为10（-6））;（B）与发出的第28条报告相比，收件人的答复严重不足;（c）大型机构的收件人比小型机构更有可能作出答复;（d）实质性的补救行动只出现在另一部分收件人的答复中;以及（e）在第28条报告中，新生儿的性别比例失衡是最难以解释的。结论是，第28条报告制度在许多方面是偶然的。作为H.M.的唯一官方出版物。死因裁判法庭规例第28条的报告书有很大的改善空间，这可能会促进死者家属和广大公众对研讯过程的支持。提出了工艺改进建议。
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 p approximate to 10(-6)); (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.