You are in the PFD Zone
Prevention of Future Deaths
Introduction
​
I carried out this research in September 2024. It looks at recent Prevention of Future Deaths (PFD) reports which have identified a lack of information sharing or communication as a cause for concern.
The judiciary.uk website does not categorise PFD reports by the type of concern they raise. The research involved reading 700+ reports and identifying recurring themes. I cannot guarantee that there are no errors or omissions, either in the data gathered through the research or in the conclusions I draw from it.
PFD reports - an overview
​
-
Issued by HM Coroner under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
-
​See also Chief Coroner’s Guidance
-
Identifies areas of concern and opportunities for improvement, but does not make recommendations about how they should be resolved/implemented
-
“Issuing prevention of future death (PFD) reports is an ancillary duty… PFDs are very important and can achieve a great deal when properly used, but the prevention of future deaths is not the primary function of a coroner’s investigation, which is to focus on the death of the deceased person.” (Chief Coroner’s annual report, 2023, para 1.20 (d))
-
There is no statutory means of monitoring PFDs or action taken in response.
PFD reports - basic statistics
This research exercise
​
Between September 2023 and September 2024:
​
-
743 PFD reports were issued, of which
-
228 (31%) refer to a lack of information sharing and communication. Specifically,
-
153 (21%) refer to systems and data quality issues, and
-
180 (24%) refer to process and practice issues.
Many ​PFDs refer to multiple issues and/or go to multiple recipients, so totals don't add up to 100%.
For context
​
Coroners' statistics 2023:
​
-
581,367 total deaths in England and Wales
-
194,999 deaths reported to Coroners
-
86,014 post mortems held
-
36,855 inquests opened
-
569 PFD reports issued
PFD reports - further detail
-
Full list of PFD reports raising communication or information sharing issues
-
Preventable Deaths Tracker (external link)
-
Workforce and patient safety: electronic communications on patient discharge from acute hospitals (external link) - a report by the Health Services Safety Investigations Body, published on 10 July 2025, which adds considerable evidence, particularly in respect of systems and data quality issues. The report's findings include recommendations for DHSC, NHS England, Integrated Care Boards, and local services.
