If a report is written it is sent to the person or authority who has the power to respond to the concern raised and to facilitate changes. This is a case-specific decision, but common examples include hospitals, healthcare organisations, governmental bodies and regulators. A PFD report can be sent to multiple recipients, if appropriate, or a number of reports can be prepared in the same case. The report will highlight the cause for the coroner’s concern, with brief details of the issues which have been brought to light in the inquest.
The recipient has to respond to the report within 56 days explaining what action they have taken, or plan to take. An extension of time may be granted at the discretion of the individual coroner who issued the report.
The Chief Coroner’s guidance states that a PFD report should raise issues and is a recommendation that action should be taken, but should not specify what that action should be (as that is for the recipient to consider/decide).
When a coroner makes a PFD report, a copy of the report will be sent the Chief Coroner as well as the intended recipient/s. In most cases the Chief Coroner will publish the PFD report on the Courts and Tribunals Judiciary website.
What are the consequences of a PFD report?
PFD reports are regarded as a powerful mechanism for positive change. They can result in improvements in policy, process and systems which directly reduce the risk of harm to others and improve the quality of care people receive.
No body/organisation wants to be the recipient of a PFD. A PFD report draws negative attention on the recipient, by airing the coroner’s concerns in a public manner.
PFD reports commonly note in how those systems and/or services are currently failing to operate adequately. This can sometimes lead to further scrutiny and invite the need for further investigation from other relevant bodies.