Key takeaways
Lesson learning statements show proactive action
Demonstrate improvements to prevent future deaths
Clear evidence strengthens your inquest response
Provide audits, training records and direct proof
Early preparation avoids last minute challenges
Start drafting and gathering evidence well ahead
What is a lesson learning statement?
A lesson learning statement is used in an inquest to demonstrate learning and actions taken by organisations (for example, Trusts and healthcare providers) following a death.
Why are lesson learning statements completed?
Regulation 28 (Prevention of Future Deaths reports) – the Coroners and Justice Act 2009 requires a coroner to issue a Regulation 28 report to an individual, organisations, local authorities, government departments and agencies where the Coroner believes that action should be taken to prevent future deaths.
They are not officially a punitive measure, but Trusts/healthcare providers will want to avoid such reports. They are carefully monitored by the CQC, who may then do an unannounced inspection to review the issues raised. There is also increasing press scrutiny of such reports.
Lesson learning statements are used to demonstrate learning and actions taken following a person’s death to prevent another death happening due to similar circumstances. An effective learning statement reduces the likelihood of receiving a Regulation 28 report, because the underlying issue has been resolved and therefore no longer poses a risk of death in the future.
How to write a lesson learning statement:
Read any reviews conducted following the death of the deceased – these might be internal reviews or external reviews.
With the new PSIRF process, healthcare organisations may need to start considering bespoke action plans for Coroners courts, as PSIRF is more about thematic learning.
Pick out each learning point and required action(s) to address learning
Detail:
What the action is
How the learning is being implemented e.g. through training sessions, email reminders, reminders during MDT meetings
How compliance is monitored – ideally, with up-to-date audit figures
Organisations should avoid technical language – there are often a lot of terms that families, legal representatives and the Coroner may not understand
As far as possible, provide evidence to support the learning. For example, if a quality alert email was sent, then produce a copy of this.
Avoid indirect or circuitous language – it makes Coroners suspicious! The best evidence is usually straightforward and direct
When should the lesson learning statement be drafted?
Start the lesson learning statement early.
For any death that will be in the Coroner’s court, identify the appropriate lesson learning witness at an early stage.
Gather the evidence throughout the process, to save searching emails for it many months later.
Aim to send a completed lesson learning statement to the Coroner several weeks before the inquest. This gives them, and the Family, time to read it.
Example section of a lesson learning report:
The Trust’s investigation identified that staff were not correctly recording the times on the observation sheet.
The action was to revise the observation sheet to encourage accurate time recording. This action is complete.
The observation sheets were redrafted to make it clear that staff should not “round up” the time they saw a patient. I exhibit a copy of the new style observation sheet as Exhibit LL/1.
The new observation sheets were rolled out on 1 January 2025.
Staff were trained on the new observation sheets. 96% of staff have completed the training, against a KPI of 90%.
The use of the new observation sheets is audited both for their use, and the quality of their use. The last audit was on 1 March 2025 and there was 97% compliance.
In addition, the ward now has CCTV installed. The ward matron does a monthly “dip check” of 5 observation sheets and compares it against what can be seen on the CCTV. The last CCTV audit was on 28 February 2025 and showed only one observations of concern, in the 40 observations that were seen to take place. The observation of concern has been raised with the healthcare assistant involved in clinical supervision and no further concerns have been noted.