October 26, 2023

Independent report demands more must be done to learn lessons from the inquest process

15 years ago, the Coroner’s and Justice Act 2009 placed a duty on coroners to make reports to relevant bodies where there is a risk that further deaths will occur if improvements and action is not taken. Prevention of Future Deaths Reports - known as PFDs or Regulation 28 reports - are a key mechanism for organisations to learn vital lessons from tragic circumstances of people’s deaths and ensure that the same situation is not repeated.

What do Prevention of Future Deaths Reports do?

PFDs can range from suggesting very specific concerns such as an individual road intersection not having adequate traffic signalling, to more wide-ranging concerns such as, identifying that there is no national guidance for police or paramedics on the management of Acute Behavioural Disturbance (ABD).

Bereaved families we represent during the inquest process often tell us that the most important outcome for them is ensuring that lessons are learnt from their loved one’s death so that another family will not have someone die in similar circumstances.

The inquest process may identify inadequacies in guidelines, resourcing, care, training or systems and a PFD report can highlight this to those with the power to improve things and mitigate risks.

How can Prevention of Future Deaths Reports be improved?

This week, the Independent Advisory Panel on Deaths in Custody produced a report looking at how effective the PFD process is and how it can be improved.

The report echoed our experience that this vital mechanism for change and improvement isn’t welcomed or taken advantage of by the agencies who receive them, isn’t shared widely enough and lacks any oversight body to identify key themes from PFDs and effect change more widely.

Most importantly, the report identified that coroners (like our clients) feel a deep frustration that the matters of concern, identified in their reports by the inquest investigation, are not properly and comprehensively addressed by respondents, and that many cases do not receive a response at all. Perhaps most depressingly, the report also highlighted coroners see deaths in circumstances that they have previously warned about, and written PFD reports on,  essentially showing that organisations are unwilling, or unable, to learn lessons.

The IAPDC’s report makes a number of recommendations to try and improve the effectiveness of PFD reports. These include:

  • That organisations should see PFDs not as a criticism but as an opportunity to improve, share good practice, and ultimately prevent deaths. In our view, this often requires a cultural change at Trusts or within the prison service from trying desperately to avoid getting a PFD during an inquest, and instead approaching a family’s concerns with openness and with a willingness to change and improve.

As part of this, the report identifies, recipients of PFD reports should make sure that they provide high quality, considered, and fully informed responses. The follow-up actions then taken should be both practical and time-specific.

A current issue that makes the PFD system less effective is that whilst recipients have a legal duty to respond to a PFD report, there is no sanction if they do not do so. In addition to this, coroners have no powers or duties to follow up where their concerns have not been addressed.

  • That the Government should fund and provide support for a research function to draw learning from PFD reports more widely. This learning should include, identifying themes and trends, as well as the timeliness and quality of responses. Going further than this recommendation, INQUEST and other organisations, have suggested that a greater impact from PFDs could be obtained from a National Oversight Mechanism – a more independent body, focusing on the outcome of PFD reports and with the power to compel organisations to provide information on the action taken (or not taken) following recommendations in inquiries or inquests following a death.
  • That PFD reports should be shared widely with organisations and bodies across the country. For example; where a concern is raised within a mental health trust in Cornwall, the report and learning could be disseminated to other mental health trusts across the country. Then if similar issues are present in a Trust in Northumberland, they can be identified and the risks mitigated to hopefully save lives.

Our opinion

The Independent Advisory Panel on Deaths in Custody report is very welcome, and clearly highlights some of the ways that PFD reports can be made more effective. Ultimately, however, it is our view that for real changes to occur, and concerns to be addressed, a true culture shift within state organisations is required to welcome criticism, learn lessons when things have gone wrong, and to proactively make improvements to mitigate the risks of future deaths.

We also fully support INQUEST’s call for a National Oversight Mechanism that would go a long way to trying to ensure that concerns raised in PFD reports are not forgotten or filed away, but properly acted upon.

Man's hand holding a jigsaw piece whilst he's sat at a table putting an incomplete jigsaw puzzle together

Here to ensure that lessons are learned

When harm is caused, either to yourself or a loved one, you want to know how it happened and to ensure it doesn’t happen to others.

Whether you’ve sustained an injury as a result of medical negligence, been involved in a life changing accident, or suffered the death of someone close to you, our legal experts understand how important it is to seek answers about what happened.

Read more stories from our Injury team highlighting how our team seeks to identify issues in care and safety, and to ensure lessons are learned when things go wrong.

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