Key takeaways
Rising PFD volumes highlight system strain and limitations
More reports issued, but impact unclear without enforceable follow-through.
Lack of oversight weakens accountability and learning
Inconsistent reports show reputational pressure alone isn’t enough.
Proactive governance is essential for meaningful improvement
Board-level ownership and robust learning processes strengthen responses.
Regulation 28 reports, or Prevention of Future Death Reports (PFDs) are intended to sit at the heart of the coroner system’s learning function. They provide a mechanism for coroners to raise concerns where they identify circumstances that could create a risk of future deaths, prompting organisations to consider taking action to prevent similar risks arising again. They remain one of the few tools capable of formally translating individual inquests into organisational learning. Yet, as their use expands, concerns about their effectiveness, enforceability and long term impact are becoming more pronounced. Recent years have seen a rise in PFD reports, with coroners issuing 713 PFD reports in 2024, up from 569 in 2023, representing a 25% increase. This growth suggests heightened vigilance but raises the uneasy question of whether an increase in reports genuinely leads to safer systems - or whether more warnings are being generated that too often go unacted upon.
Under current legislation, organisations must respond to PFDs within 56 days, stating what action they will take or providing reasons for taking none. In practice, compliance is inconsistent. Some organisations respond inadequately, late, or not at all, despite the introduction of the Chief Coroner’s 'name and shame' approach, which publicly lists non responders to apply reputational pressure. Yet reputational levers alone have limited force. Recent research into maternal deaths illustrates this sharply: PFD reports in these cases were found to be routinely not acted upon, with 62% of maternal death PFDs receiving no response from the relevant organisations. Such trends demonstrate that without statutory sanctions or an oversight body empowered to enforce compliance, PFD responses risk remaining performative rather than transformative.
The rising volume of reports also brings the risk of impact dilution. As more PFDs are issued, each one may attract diminishing attention from executives, regulators and the media. Organisations already navigating substantial regulatory responsibilities may struggle to elevate PFD learning above other competing priorities. Meanwhile, research into preventable maternal deaths found repeated themes such as failures in treatment, delayed escalation, poor recognition of risk factors and inadequate staff training- concerns raised across multiple reports but not systematically addressed at a national level. When such recurring issues persist despite having been repeatedly highlighted by coroners, it becomes harder to argue that the current system is functioning as an effective driver of scrutiny or improvement.
The PFD system relies heavily on organisations engaging with the process constructively - considering the coroner’s concerns, identifying appropriate actions, and embedding them into their own governance frameworks. By contrast, safety critical sectors like aviation, nuclear energy and pharmaceuticals mandate externally monitored, enforceable actions when systemic risks are identified.
For healthcare organisations, these challenges carry significant operational and cultural implications. Failing to respond meaningfully to PFDs risks reputational damage and undermines trust in governance, particularly in an NHS already under strain and subject to intense scrutiny following high‑profile care failures. Conversely, timely, substantive engagement with PFDs can demonstrate organisational commitment to transparency, accountability and continuous improvement.
In the absence of formal enforcement mechanisms, organisations can nevertheless take practical steps to strengthen their approach:
Treat PFD responses as board‑level issues, ensuring clear executive ownership and effective oversight.
Integrate learning from PFDs into risk registers, quality‑improvement programmes and patient‑safety governance structures.
Apply robust root‑cause analysis to develop meaningful and actionable responses.
Share PFD‑related learning across departments and systems to avoid siloed or repeated failures.
Audit and monitor follow‑through on PFD‑linked actions to ensure that planned improvements are implemented and sustained.
Ultimately, the PFD system now sits at a crossroads. Coroners are issuing more reports than ever, identifying risks with increasing clarity and urgency. Yet without stronger oversight or enforceable duties, the gap between identifying risks and acting on them may continue to widen. The credibility of the system- and its ability to prevent future deaths- rests on whether it can evolve from a largely advisory model to one underpinned by clearer expectations, firmer accountability and mechanisms that ensure lessons identified truly become lessons learned.
This article was co-authored by Paralegal, Kate Sheppard.
