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Caroline Flint wrote to Arthur Hooper to confirm that a vCJD expert group had been set up, as it was it important that patients be given choice when they have been informed they are at risk.

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Cardiologist Mark Petrie noted in an internal email during the Penrose Inquiry that very little guidance was given to Doctors on how to fill in death certificates.

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The Penrose Inquiry investigated into the deaths of Eileen O'Hara and the Reverend David Black, a fatal accident which had been sought in a previous judicial review.

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R v HM Coroner for the Western District of Somerset ex parte Middleton considered the inquest investigation required when Article 2 of the European Convention on Human Rights (the right to life) is engaged.

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In the Third Report of the Shipman Inquiry, Dame Janet Smith noted that the system of death certification which had operated during the 1970s, 1980s and 1990s was not working well and was in need of radical reform.

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In the Third Report of the Shipman Inquiry, Dame Janet Smith noted that an inquest should solely focus on answering who the deceased was; how, when and where the deceased came by his death; and the particulars for the time being required by the Registration Act to be registered concerning the death.

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In the Third Report of the Shipman Inquiry, Dame Janet Smith considered that the death certification process should include a brief summary of the deceased's recent medical history and the chain of events leading to death. The forms she proposed for use contained a box in which the doctor could express an opinion as to the cause of death.

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In the Review of Fatal Accident Inquiry Legislation 2009, it was found that the sheriff courts in Scotland were "intimidating" and tended "to have an adversarial atmosphere."

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NHS England and NHS Wales began to implement medical examiner systems whereby all deaths would be independently scrutinised by medical examiners if they are not referred to the coroner.

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A Fundamental Review of Death Certification and Investigation in England, Wales and Northern Ireland took place in the wake of the Shipman scandal, the deaths caused by Beverley Allitt, and the deaths of "heart babies" at Bristol Royal Infirmary. It considered death certification and the coroner's jurisdiction, identified weaknesses in the death certification process, and made recommendations.

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The Select Committee on Delegated Powers and Regulatory Reform reported that a proposal for civil registration reform was not an appropriate subject for a regulatory reform order.

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The Coroners (Amendment) Rules 1980 first provided Coroners with the power to report matters to a person or authority who is able to take action to prevent the recurrence of similar fatalities.

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The Coroners Act 1887 outlined the circumstances in which an inquest was required, and included when there was reasonable cause to suspect a violent or an unnatural death, or when a sudden death occurs from an unknown cause.

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The Coroners Act 1887 established the four questions that continue to be answered by inquests today: "who the deceased was, and how, when, and where the deceased came by his death".

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The Coroners Act (Northern Ireland) 1959 provided that the coroner may hold an inquest in several circumstances, including where there has been an unexpected or unexplained death, or a death in suspicious circumstances. An inquest could be held without a jury but a jury was required when "the death occurred in circumstances the continuance or possible recurrence of which is prejudicial to the health or safety of the public or any section of the public."

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Rule 43 of the Coroners Rules 1984 provided that if a Coroner believed that action should be taken to prevent the recurrence of fatalities similar to that in respect of which the inquest was occurring, they could report matters to a person or authority who is able to take action.

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The House of Commons Library Briefing Paper 'The Office of the Chief Coroner' was published.

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Wide-scale reforms to the coronial system were introduced in England and Wales, and included the introduction of the Coroners (Inquests) Rules 2013.

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The Coroners (Inquests) Rules 2013 provided that determination can be given with a variety of possible short conclusions, an open verdict and/or can comprise a brief narrative conclusion expressed in concise and ordinary language so as to indicate how the deceased came by their death.

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Section 24 of the Registration of Births, Deaths and Marriages (Scotland) Act 1965 provided that a doctor must state the cause of death and such other medical information as required.

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