Prevention of Future Deaths (PFD) Reports – what you need to know

A Prevention of Future Deaths report is a formal document prepared by a coroner to address concerns which have arisen during the course of an inquest investigation. They are also known as PFD reports, or Regulation 28 Reports.

When is a PFD required?

A coroner is under a duty to make a PFD report where they have concerns that further deaths will occur in the future and believes that action should be taken to prevent future deaths.

When considering whether a PFD report is required, the coroner should focus on the current position by considering evidence and information about relevant changes made since the death, or any plans to implement such changes.

If the coroner is satisfied that the potential PFD recipient has already implemented suitable action to address the risk of future deaths, the coroner may not need to need to make a report.

At what stage is a PFD report made?

A report may not be made until the coroner has considered all the documents, evidence, and information that in the opinion of the coroner are relevant to the investigation. For this reason they are most commonly issued at the end of the inquest investigation, but a coroner can prepare a PFD at any time during the inquest process once the threshold is met.

PFD reports are made pursuant to paragraph 7(1) of Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroner’s (Investigations) Regulations 2013.

Is a PFD report and regulation 28 report the same thing?

Yes. PFD report and Regulation 28 report refer to the same thing.

The power to issue such a report by a coroner comes from Regulation 28 of the Coroner’s (Inquests) Regulations 2013, hence the name.

Throughout the inquest investigation the coroner should be mindful of their duty under the relevant legislation mentioned, however it is sensible to make your concerns known from an early stage if you have any.

Usually the coroner will invite submissions at the end of the inquest hearing as to whether a PFD report should be written and on what issues. Coroners are influenced by the submissions of the family and other participants, but is ultimately the coroner’s decision.

Having specialist inquest representation will ensure that this is borne in mind from the outset, and that the appropriate evidence is heard by the coroner to fully consider whether a PFD report ought to be written.

It is ultimately for the coroner to decide if a report is warranted, and what the report should focus on.

Coroners have discretion as to the focus of their concerns but generally speaking PFDs should be intended to improve public health, welfare, and safety.

Our inquest specialists have recently been involved in inquests where PFD reports have arisen in the following circumstances:

• Concerns about unsafe staffing levels, inadequate training for staff, inadequate policies, failure in leadership and failure in the duty of candour;
• Concerns that a local authority did not have adequate defibrillator machines on its supported living site;
• Concerns that a hospital did not have a proper system in place for alerting its staff when a patient had not received medication which was needed at very precise intervals of time;
• Concerns that a newborn baby was not assessed at the same time as its mother when she attended hospital with signs of a serious infection shortly after the baby was born;
• Concerns that an NHS oncology service was not adequately staffed and did not have sufficient expertise in its leadership team;
• Concerns that a mental health team were not undertaking adequate observations and not appropriately record-keeping,

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.

Inquests and claims for compensation following a death are separate processes but often evidence gathered throughout the course of an inquest can be useful for a claim which follows.

Whilst a PFD report may be further proof of the nature of the coroner’s concerns, the report itself won’t determine whether a claim can be pursued. This is because the scope and legal tests which apply in an inquest are different to those in a civil claim.

It is important to note that claims are often successfully pursued after inquests where no PFD report was written. As a PFD report is only written where there is an ongoing concern of a risk of deaths, the fact a care provider made improvements since the incident would not alter the fact that care may have been substandard at the time.