Coroners are legally obligated to notify public bodies, including government ministers and departments, healthcare organizations, prisons, and regulatory agencies, when they believe there’s a risk of future deaths if corrective action isn’t taken. The way this information is communicated to relevant parties is through the preparation of a Prevention of Future Deaths report (PFD).
While recipients are required to provide a written response to the coroner’s concerns, they are not legally bound to implement specific measures to address the identified risks.
According to The Times Failure to act on coroners’ advice blamed for thousands of deaths over 5,400 Prevention of Future Deaths (PFD) reports have been issued by the Chief Coroner since 2013. These reports identify areas where improvements, such as better record-keeping, staff training, clearer medication labelling, and enhanced care services, could potentially prevent future deaths.
Analysis by the Preventable Deaths Tracker project at King’s College London has shown that a significant number of these reports have received inadequate responses from the relevant authorities. Specifically, 1,495 reports (27%) have not received any response, and another 741 (14%) received only partial responses. In 2024 we saw 672 PFDs being published, which is the highest number of reports in a year to date.
Jackie Linehan, Legal Director at Enable Law said:
‘It is very disappointing to families who have been through an Inquest where a Preventing Future Deaths report has been issued, to learn that the Coroner has no power to enforce the recommended change and that there is no effective centralised system for sharing that learning’
An Inquest is a fact-finding exercise into the how, when, and why someone died. It is not criminal proceeding and cannot on its own provide remedies to the loved ones of the deceased either in terms of compensation for the financial losses they may have suffered because of their loss or in holding the individual or organisation that is found to have contributed to their death accountable to justice.
What does this mean?
In the UK, an Inquest will happen if there’s reasonable cause to suspect that the death was due to anything other than natural causes. Even though the outcome of an Inquest can not in itself drive change to prevent what led to someone’s death being repeated, it is a valuable way to get answers to what led to their death.
At Enable law we have specialist solicitors that support clients who have concerns that the death of their loved one may have been caused by medical negligence. We also have a dedicated team specialising in supporting individuals who have experienced the loss of a loved one due to fatal accidents, whether they occurred at work, on the road, or in public space. The teams are led by Mike Bird, Clinical Negligence Partner and part time Assistant Coroner whose experience in running Inquests is an invaluable asset for our clients.
How can we help you?
A PFD report can make recommendations to prevent future deaths but cannot enforce them. Making a successful claim for compensation following the loss of a loved one can put more pressure on those found to have contributed or led to a death.
Outside of answers, you may get an admission of liability as well as financial compensation to help you and any dependents of the deceased deal with any financial difficulties you may be facing as a result of the loss.
No amount of money can bring your loved one back, but it can help you stop worrying about finances whilst you are grieving.
Within our team we also have professionals specialising in working with the press to affect wider change. Epidemiologist and Founder of the Preventable Deaths Tracker recently said in her Times interview that “change comes from additional factors like change in leadership of the organisation, huge media scrutiny or dedicated families “.
To speak to a dedicated inquest and fatal claims solicitor call us today on 0800 044 8488 or fill in our contact form so we can get in touch with you at a time convenient to you.