Prevention of Future Death Reports: What You Need to Know in 2025

Articles

22/01/2025

Prevention of Future Death reports (“PFDs”) are an increasingly utilised tool in inquests, by which a coroner can draw attention to matters for which action could be taken to prevent future deaths. In 2023, the number of PFDs issued by coroners increased to 550 reports, in comparison to 418 reports in 2022. Whilst the Chief Coroner’s Annual Report for 2024 has yet to be published, one can only expect that the figure will again likely increase. However, PFDs are not without their problems, particularly due to the lack of any power to compel a response. Late last year, the Chief Coroner for England and Wales, Her Honour Judge Alexia Durran, gave warning that as of 1st January this year, she will publish a list of those organisations failing to respond to prevention of future death (PFD) reports, which she termed a ’badge of dishonour’.

In this briefing, Sarah Prager KC and Dominique Smith consider PFD reports and the impact of a failure to respond. Deka Chambers is also hosting a conference in London on 13th February, Accidents and Deaths Abroad, at which Sir Peter Thornton KC, Former Chief Coroner of England and Wales, will be talking about PFD reports. Further information and booking details here.

The law

Paragraph 7(1) of Schedule 5 of the Coroners and Justice Act 2009 provides that:

(1) Where –

  1. a senior coroner has been conducting an investigation under this Part 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 should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances, the coroner must report the matter to a person who the coroner believes may have power to take such action”.

The above paragraph therefore bestows upon a coroner a duty to report matters to an appropriate person to take action to prevent future deaths in certain circumstances. Once the duty is engaged, Regulation 28 of the Coroners (Investigations) Regulations 2013 provides that the coroner must send a copy of the report to the Chief Coroner and all other interested persons after they have considered all relevant documents, evidence and information that are relevant to the investigation.   

Paragraph 7(2) of Schedule 5 provides that the person to whom any such report is made must give a written response to it, and a copy of that response must be sent to the Chief Coroner (paragraph 7(3)). Regulations 29(3) and (4) of the Coroners (Investigations) Regulations 2013 further provide that within 56 days of the report being sent, a party responding to a PFD report must provide a response to the report which must contain:

‘(a) details of any action that has been taken or which it is proposed will be taken by the person giving the response or any other person whether in response to the report or otherwise and set out a timetable of the action taken or proposed to be taken; or

(b) an explanation as to why no action is proposed’.

Discussion

What the current legislation does not do is to provide a coroner with any power to compel a response to a PFD. This is naturally problematic, as families will undoubtedly wish for organisations or individuals to take heed of the concerns raised and implement changes to prevent others dying by similar means. There is also no system of oversight, such that organisations and individuals do sometimes fail to respond, leaving the report unanswered and concerns unaddressed. There may reasons as to why reports are not responded to (albeit, they should be). Perhaps parties fear that publicly setting out proposed alterations to their existing systems may raise issues in respect of a potential civil claim, whereas parties with nothing further to add to the evidence considered by the coroner may be uncomfortable about declaring as much. Perhaps they simply do not wish to engage with the process. Notably, the Preventable Deaths Track online tool, which tracks the number of organisations and individuals who do not respond to PFDs, currently stipulates that 1,520 PFDs have had no responses published.

Irrespective of the reasons why a response may not be provided, the inability for a coroner to compel a response exposes a lacuna as to how this issue can be addressed.

In September 2024, the Chief Coroner stated that she will be publishing a list of those organisations who do not respond to a PFD. The Chief Coroner’s stated aim in publishing this list is to essentially shame them with a ‘badge of dishonour’ – there will be publicly available information that they have failed entirely to engage in providing a response to consider how lives might be saved in future. As well as inflicting reputational damage on unresponsive parties, the list is likely to be used by regulatory bodies, such as the Care Quality Commission, the Civil Aviation Authority or the General Medical Council, to identify those parties in need of investigation and potentially intervention.

The availability of a public list of parties unwilling or unable to engage in consideration of how their systems might be so hazardous as to cause death in the future will also be of interest to legal practitioners considering bringing proceedings against entities featuring on the list, either claims arising from the death prompting the inquest in question, or more generally. Failure to respond to a PFD report may be used to found a submission that the party has a cavalier approach to safety in general and, moreover, a lackadaisical attitude to matters of critical importance. After all, if a party refuses to consider how to prevent future deaths, how can it credibly submit to a judge hearing a civil claim that it invests in the health and safety of its workforce, customers, patients, or other affected members of the public? Moreover, if the parties were to be involved in a subsequent inquest arising from similar circumstances, it will undoubtedly come to the coroner’s attention that they have failed to act upon, and indeed engage, with previous concerns raised in a PFD, which could impact the conclusions reached.

Given the Chief Coroner intends to name and shame unresponsive parties, it is all the more important that all interested persons play an active role in inquests, including the subsequent reporting process. It is also important that any potential litigators are involved in scrutinising this crucial (and time-limited) accountability mechanism; once the civil claim is issued, the response time will often have passed, the list will have been published, and the defendant will have been exposed as failing to engage with a coroner. We can expect civil judges to take an increasingly dim view of such failings.

Featured Counsel

Sarah Prager KC

Call 1997 | Silk 2023

Dominique Smith

Call 2016

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