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.