Enhancing Safety – Understanding Reports To Prevent Future Deaths By Coroners

Coroners in England and Wales play a crucial role in investigating deaths that occur under specific circumstances. Beyond determining the cause of death, in certain cases, the coroner has a duty to provide a report called a Report to Prevent Future Deaths.  These are also called PFD reports or Regulation 28 reports.

The coroner’s aim in writing such a report is to prevent future fatalities by identifying systemic issues and requiring those with the “power to take such action” to do so to avoid future deaths.  Such reports are written with the intention of improving “public health, welfare and safety”.

When are Reports to Prevent Future Deaths issued?

Reports to Prevent Future Deaths are issued by Coroners following the conclusion of an inquest where they identify circumstances or practices that, if left unaddressed, could lead to similar deaths in the future.

PFD reports are not confined to the healthcare sector; they can encompass a wide range of settings, including prisons, workplaces, transportation systems, and public services. It provides a system of accountability with an aim to foster change and avoid a similar death from occurring in the future.

What process is involved in issuing Reports to Prevent Future Deaths ?

If the coroner’s investigation into the death has revealed a concern that “circumstances creating a risk of other deaths will occur, or will continue to exist in the future” they have a duty to send a PFD report to a relevant organisation or individual.  These reports must state:

The coroner should not specify what actions they consider should be taken. That is a matter for the recipient of the report to consider.

The coroner’s concerns do not need to arise from something that has caused the death they are investigating. Anything can be considered that comes up during the coroner’s investigation.  This means that the subject of a PFD report can be something peripheral to the death under investigation during that particular inquest.

Further, any evidence that comes up can be relevant, so anything that is considered as part of the investigation that leads to the inquest can be used to form the subject of a PFD report.

Timescales

The coroner must submit the report to the relevant party within 10 working days of end of the inquest. Alternatively, the report can be written before the inquest concludes and should then be written within 10 working days of the time when the coroner identified the relevant issue to be included in a PFD report. Usually, they are written after the conclusion of the inquest so that all relevant evidence has been considered but there are exceptions.

Unfortunately, the coroner has no power to compel the recipient of a PFD report to respond, or to implement any of the coroner’s recommendations.  Where they do respond to the report, they must do so within 56 days. The coroner must file a copy of the report plus any response if one is provided with the Chief Coroner.

Can a coroner be asked to write a PFD report?

Submissions can be made during the course of the inquest. The coroner will listen to submissions made by family members or other participants but ultimately the decision to write such a report rests with the coroner.

Specialist legal representation is essential to ensure that appropriate and effective recommendations are made and that the coroner is provided with all relevant evidence to take into account when deciding whether to write a PFD report.

Impact of Reports to Prevent Future Deaths and the subsequent implementation

The impact of PFD reports extends beyond the immediate aftermath of a death investigation. The key purpose is to highlight concerns and to prompt a review of services to try and improve safety of service users.

Conclusion

Reports to Prevent Future Deaths are an important mechanism for change by which a Coroner can use the information gleaned from the investigation into one person’s death (or group of persons) to try to avoid a set of circumstances that could lead to unsafe processes putting further lives at risk. They are crucial to bereaved families who are very often eager to ensure the circumstances that led to the loss of their loved one do not happen to another family.

As we strive to create safer environments and protect the welfare of individuals, the ongoing commitment to learning from past tragedies and implementing proactive measures remains paramount. By responding positively to such reports, those with “the power to take action” can help to restore the faith of a bereaved family that their loved one did not die in vain.