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A thematic review of recent Prevention of Future Deaths (‘PFD’) reports

A thematic review of recent Prevention of Future Deaths (‘PFD’) reports

What are PFD reports?

Throughout the coronial process, coroners have a duty to issue PFD reports, also known as Regulation 28 reports, where there is a concern that further deaths will occur in similar or the same circumstances. Once a PFD report has been issued, a person or organisation must provide a response, which may be published. For more information on PFDs and what they mean for an organisation, please refer to our analysis here.

This article offers a review of recent PFD reports that have been issued. It will highlight the emerging themes and circumstances in which coroners are finding their duty is engaged, to ensure healthcare providers are learning from deaths.

Observations in mental health inquests

In an inpatient mental health setting, effective observations are a key element to managing risk and ensuring patient safety. On review of recent PFD reports from this calendar year alone, it is apparent that coroners are particularly concerned with the following aspects of observations:

  1. They should not be carried out in a way which is ‘prescriptive and predictable’
  2. Record keeping should not be seen as a tick box exercise, merely utilising a ‘cut and paste’ function

In a recent case, a coroner issued a PFD report almost immediately after notification of a death (before the inquest had been heard), as there were significant concerns regarding the level and frequency of observations upon the deceased. The coroner noted that the five minute observations upon the deceased were recorded exactly on every fifth minute which allowed her to plan to sadly take her own life between observations.

Similarly, in another jurisdiction, a coroner considered their duty to issue a PFD report was engaged where they were particularly concerned that in the period before the deceased’s death, staff were observing her in a way which was ‘predictable and prescriptive’.

In that same matter, the coroner also highlighted a concern regarding the quality of observations records, determining that these were not in accordance with the expectation of policy. This was raised in another inquest in a different jurisdiction. The concerns about record keeping were twofold: that the notes fell short of recording how the individual presented and that they appeared to have been created utilising a “cut and paste” function.

Deaths in prison custody

A significant proportion of PFD reports issued over the past year raise concerns in relation to inadequate staffing levels within prisons and the impact that has on the safety of prisoners.

Insufficient staffing has a range of dangerous effects. With insufficient staff, it is far more difficult to effectively mitigate suicide risk factors within prisons, such as detecting mental ill health, self-harm and missed health care appointments as a result of a lack of staff to escort prisoners to those appointments.

A recent example is a PFD report relating to a death in prison custody. During the course of the inquest evidence, it was found that the failure to provide adequate psychological support contributed to his death. Other issues which were deemed to be relevant to the circumstances of his death included staff shortages and gaps in training. The coroner’s main concerns related to inadequate staffing levels, with particular emphasis on the safety of the deceased being compromised as a result of staff shortages.

Inadequate staffing is a recurring theme in PFD reports and with this likely to be an ongoing theme, it is important for other healthcare providers to consider the potential impact of current and anticipated staff shortages on future deaths.

A recent example of a Trust acting to learn lessons ahead of a PFD report being issued relates to a recent inquest touching upon a death in prison. Prior to the death, it was not policy for a mental health nurse to attend every Assessment, Care in Custody and Teamwork (‘ACCT’) review (ACCT is the care planning process for prisoners identified as being at risk of suicide or self-harm). The coroner raised concerns during the inquest investigation about the effective risk management of the deceased. The Trust amended its policy to include the requirement for a mental health nurse to attend every ACCT review, ensuring that the mental health team are able to contribute to decisions regarding the actions required to mitigate the risk of harm, and input into the ACCT care plan. The coroner was satisfied the change in policy was sufficient and no PFD report was issued.

Preventable Deaths Tracker

It is important to remember that the fundamental component of ensuring the central purpose of PFD reports is to promote learning and, particularly in a healthcare setting, to improve patient safety and welfare. Organisations should be aware of the reoccurring themes amongst PFD reports. The Preventable Deaths Tracker database which has recently been published by Dr Georgia Richards and her team is a useful resource and can be found here.

For further information and support, please get in touch. 

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