Prevention of Future Deaths
Introduction
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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.
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PFD reports - an overview
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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.
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​See also Chief Coroner’s Guidance
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Identifies areas of concern and opportunities for improvement, but does not make recommendations about how they should be resolved/implemented
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“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))
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There is no statutory means of monitoring PFDs or action taken in response.
PFD reports - basic statistics
This research exercise
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Between September 2023 and September 2024:
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743 PFD reports were issued, of which
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228 (31%) refer to a lack of information sharing and communication. Specifically,
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153 (21%) refer to systems and data quality issues, and
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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
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Coroners' statistics 2023:
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581,367 total deaths in England and Wales
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194,999 deaths reported to Coroners
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86,014 post mortems held
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36,855 inquests opened
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569 PFD reports issued
