Prevention of Future Deaths reports

Whilst the key focus of an inquest is usually the question of how a person came by their death, for many Interested Persons, including NHS trusts and other healthcare providers, the most important issue is whether the coroner will issue a Prevention of Future Deaths report. Prevention of Future Deaths reports (PFD Reports), also known as ‘Regulation 28 reports’, are made pursuant to paragraph 7(1) of Schedule 5 of the Coroners and Justice Act 2009 and Regulation 28 of the Coroners (Investigations) Regulations 2013. 

A coroner has a duty to take action to prevent future deaths where:

1. a coroner has been conducting an investigation into a person’s death;
2. anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist in the future; and
3. in the coroner’s opinion, action is required to prevent the continuation of such circumstances, or eliminate or reduce the risk of future death created by such circumstances.

It is a common misconception that such a duty will only arise in cases where actions or omissions may have caused or contributed to the person’s death. As per the Chief Coroner’s Guidance No. 5, PFD Reports are not restricted to matters causative, and emphasis is given to paragraph (2) above, in that ‘anything revealed’ during the investigation may trigger the duty.

From a healthcare perspective, PFD Reports are not designed to be punitive, and are a powerful mechanism by which to improve public health, welfare and safety. However, the implications of a healthcare provider receiving a PFD Report are considerable. All PFD Reports are published online and therefore the reputational impact can be significant. Additionally, and perhaps more importantly, the coroner will also send the report to any other person who may find it useful or of interest. This would usually include the CQC (Care Quality Commission). The recipient of a PFD Report must respond in writing within 56 days from the date the report was sent, setting out the action that has been taken, or is proposed to be taken. Alternatively, it must set out why no action is proposed. This response may also be published and will be shared with all other interested persons the coroner believes should receive it. Again, the coroner may also share this with any other person he or she believes may find it useful or of interest. This is of course extremely important from a reputational perspective, and careful consideration should be given when drafting responses.

It is important to note that in the event a duty to report arises, the coroner must only report the matter to whoever the coroner believes may have the power to take the action required. For instance, in the case of a death of a hospital patient, it may not be appropriate to make a report to the provider, but rather NHS England, if the provider was following national guidance. Furthermore, the risk of future deaths must be considered by the coroner at the time of the inquest, not the time of the person’s death. Consequently, the coroner must consider any evidence presented as to the action taken to improve services following the events surrounding the person’s death. The purpose of a report is to address risk and should be designed to have practical effect. As such, in the event that necessary measures are taken, or are being taken, the report would have no practical effect and would not be appropriate. 

In order to mitigate the risk of a PFD Report being issued, it is vital that healthcare providers identify potential issues in care or service delivery at an early stage, so that appropriate action can be taken to improve services in advance of the inquest hearing. It is important to note that any such issues creating a risk will not always be covered in the internal or external review of the care and treatment, and a comprehensive analysis will be necessary in most cases.