Learning Lessons in Healthcare:

Learning Lessons in Healthcare: the evolution of Prevention of Future Deaths (PFD) reports and consequent implications

Contrary to sensationalist reports in the national media, it is widely recognised by those working in the health and social care sector that such organisations strive to improve and to learn lessons from mistakes. One of the functions of the Coroner (sometimes referred to as the secondary function, the primary being to establish who, when, where and how the person died) is to ensure that when mistakes are made, those lessons are learned and action taken to avoid the same mistakes being made in the future. Even when mistakes are not made, it is important that organisations continue to learn. 

Those organisations who do not respond to a PFD report – either by way of a substantive response or seeking an extension to provide the substantive response – within the 56 days set out in law are being named and shamed on an annual list. Being identified on this list should be considered to be, according to the Chief Coroner, a “Badge of Dishonour”.

What next? 

As it stands, when issuing a PFD report the Coroner is still only permitted to raise concerns. How (and if) those concerns are acted upon is entirely a matter for the agency in receipt of the report, beyond there being a statutory requirement for an investigation and response in 56 days. There is no provision for the Coroner to enter into a dialogue about ongoing changes and no provision, if the Coroner is dissatisfied with the outcome of any investigations into the concerns raised, for the Coroner to ask that the matter be revisited. The response should be published alongside the PFD report but there the story ends.

However, there are other ways in which a PFD report can be used to highlight concerns. Most, if not all, Coroners will send PFD reports to the Care Quality Commission – repeated issues are likely to result in an increased focus at the next inspection or, subject to the gravity of those concerns, may result in an inspection taking place. 

Commissioners 

If the Coroner is concerned about the provider of a service and/or specific issues, there would be nothing to prevent the Coroner sending a PFD report to the commissioner of that service. Such a report may, for example, highlight the concerns surrounding a particular service and the onus will be on the commissioner to investigate the concerns raised.

Procurement

More and more frequently we are seeing procurement exercises which include a requirement for confirmation that the organisation has not received a PFD report.

It is not a big leap to see a situation in which procurement exercises include a request for confirmation that a tendering organisation has not been given the “Badge of Dishonour”. 

Reputation

Historically whilst organisations worked hard to avoid a PFD report, there were few repercussions attached to the report being issued and any subsequent response. The annual report changes this. Failing to respond will be widely known and reported on. The “naming and shaming” of organisations will inevitably have consequences reputationally which is likely to filter to commissioners and investors.

Conclusion

The Coroner’s powers insofar as inquests are largely limited to ascertaining who the deceased was, where and when they died and how they died within the narrow scope of an inquest. This secondary function, and the emphasis being placed on it by the Chief Coroner should be welcomed not as a stick to beat organisations with, but as a means to ensure that there is a genuine desire to learn – the inquest process does not stop at its conclusion.

This new approach requires clarity from organisations as to where PFD reports should be sent – it would be unfortunate if an organisation was named on the list in circumstances where the PFD report had not been responded to because it had not been sent to the correct person within an organisation. If the Coroner does indicate that a PFD report is to be sent, it is worth ensuring that the Coroner has the correct address of the person to send it to and that there are appropriate internal systems in place to ensure that all reports are sent to the correct department as a matter of urgency. 

Join healthcare legal director Rachel Kelly at LaingBuisson’s Private Healthcare Summit on Thursday 15 May at 12:30 for her session on ‘Making patient safety meaningful for patients’.

Details on Rachel’s session and the Conference Agenda can be viewed here.