Prevention of Future Death Reports: Why do we keep getting it wrong?

‘Failure’ by mental health services, ‘avoidable’ death during surgery, ‘unlawful killing’ are just three of the estimated 37,000 inquest conclusions that will be read out to grieving families in 2025.

One-fifth of deaths – 125,000 – are deemed avoidable each year in England and Wales, and require a formal, public hearing to determine where, when, and how someone died.

Through our legal PR work, we support families of the deceased through the deeply emotional process of inquests and the often intense media attention that accompanies them. A consistent wish voiced by the majority of families is to exit the painful process with a Prevention of Future Deaths report (PFD).

The statutory report, written by the coroner, addresses the failings exposed during the death investigation and is sent to all organisations that have the power to deal with the safety issues, system failings, or inadequate practices or care.

The hope is to ensure that those who have a duty of care learn vital lessons so other families do not have to face the same devastation that has torn their world apart.

But do PFD reports really hold the power to create real change and save lives?

By law, a coroner must write a report when they believe action should be taken by organisations involved, such as hospitals, the government, or the police, to deal with the issues raised and help create the robust safety system that we, as citizens, rightly assume already exists.

Despite England and Wales holding more inquests than most countries around the world, only 2% of inquests result in PFDs. This statistic is arguably at odds with the number of inquests opened each year.

Organisations have a statutory obligation to respond to the report within 56 days, yet at least half of the reports do not have publishable responses.

This is something Dr Georgia Richards, founder and director of Preventable Deaths Tracker, is on a mission to change. As an epidemiologist, Dr Richards understands the importance of reporting in a way that creates a clear system, allowing us to track information and identify patterns that ultimately achieve the report’s sole purpose – to save lives.

The Preventable Deaths Tracker is a world first with three key aims – to create a robust system with real-time analytics and statistics, to develop methods for identifying safety signals and trends from coroner’s reports and organisations’ responses, and to utilise those discoveries to educate the death investigation process to ultimately inform much needed policy change.

I recently met Dr Richards while studying a King’s College course, Death Investigations: Coroners & Inquests, taught by the former Chief Coroner for England and Wales, HH Sir Peter Thornton KC.

As an Australian, Dr Richards voiced her confusion upon discovering that the UK does not have a clear, robust system to record and monitor PFDs. In Australia and New Zealand, the information collated from every inquest is placed in the National Coronial Information System (NCIS), a transparent system which has been saving lives for 25 years.

The NCIS, which employs 10 staff, was set up in response to recommendations made following Aboriginal deaths. It is a valued resource that every Australian territory utilises to improve the justice system, health care, and ultimately prevent deaths.

In contrast, the system in England and Wales relies on a myriad of emails to be sent to multiple recipients before a response can be formulated and sent back to the coroner’s office. If a response is received by the coroner’s office, it is then forwarded to the chief coroner, who is responsible for publishing the report, with redactions.

Dr Richards estimates there is a minimum of three emails sent for each report, resulting in thousands of unnecessary pieces of correspondence before the reports are manually published on the judiciary website. In the absence of a centralised system dictating how reports are dealt with, there remains no clear national strategy to implement the life-saving recommendations the reports contain.

Worryingly, her research showed that some reports had been published with coroner errors, rendering the reports unusable from an educational and prevention perspective.

Dr Richards argues that policy and prevention are impossible to achieve without valuable insights, leaving many bereaved families to rely on the help of lawyers, often working on a pro bono basis, to achieve justice for their loved one and, in turn, expose failings.

Another deeply concerning issue around PFDs was revealed during the Lampard Inquiry this month, as evidence suggested that health trusts were repeatedly trying to stop coroners from issuing reports to protect their reputation.

The statutory inquiry, set up to investigate the deaths of mental health patients in Essex between 2000 and 2023, is the result of one mother’s decade-long campaign to understand how her 20-year-old son, Matthew Leahy, died while under the care of the trust.

While giving evidence to the inquiry, this month, Deborah Coles, director of the charity INQUEST, said: “It’s difficult to say how traumatising that is for families when they sit in at an inquest… and then see legal representatives try and effectively stop a coroner from making a Prevention of Future Deaths report, which is ultimately about trying to safeguard lives in the future – and I find that reprehensible.”

Speaking to the BBC, after giving evidence, Ms Coles added: “NHS trusts try and argue with coroners that they’ve already implemented changes and that a report is not necessary.” This ultimately removes the opportunity for local and national learnings that could lead to policy change.

Since the Prevention of Future Deaths Tracker was established in 2020, the publication rate of organisational responses went from less than one-third with published responses to almost half.

But as 25% of reports are still outstanding, it is clear there is still much work to be done.

Until a centralised system is enforced by the government, missed opportunities to save lives will be repeated, and the question will remain: When can we rely on PFDs to do what they say?