What is a Prevention of Future Deaths (PFD) Report?
The Law: Schedule 5 (7) Coroners and Justice Act 2009 Act and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013
The Law Explained: Where an inquest gives rise to a Coroner having concerns that future deaths will occur and is of the opinion that action should be taken to reduce the risk of death, the Coroner has a statutory duty to issue a report with the view of preventing future deaths. A PFD Report can be issued to an organisation or individual whom the Coroner believes may have the power to take action to prevent future deaths. A PFD Report should be sent out within 10 working days of the inquest concluding. The recipient of the PFD Report must respond in writing to the Coroner within 56 days of receiving it.
Recent PFD Reports
1. Mental healthcare related PFD Reports:
Issues at inquest giving rise to PFD Report: The Coroner heard evidence that there was insufficient guidance within the Code of Practice for clinicians on how to safeguard a patient who is awaiting a Mental Health Assessment (MHA) as this can take several hours or days to be completed.
Recipients of PFD Report: The Royal College of Psychiatrists & NHS England
Analysis: The PFD Report was issued to encourage the development of a protocol or guidance to govern the steps that should be taken to safeguard vulnerable individuals awaiting a MHA assessment who may present as at risk to themselves or the community. It is encouraging to see a Coroner acting to proactively encourage change to national guidance and reiterating the Chief Coroners’ guidance that PFD Reports should not be considered as a punishment but as a tool to benefit the public.
2. Acute Hospital care PFD Reports
Issues arising at inquest giving rise to PFD Report: The Coroner heard evidence about computerised record systems not “speaking” to each other either within the same Trust or different Trusts caring for patients within the same setting. that the NHS Trust’s Psychological Therapy service used and continued to use a different computerised record-keeping system to that used by staff providing acute mental health services. It was identified that staff groups did not necessarily have access to the different record keeping systems and therefore resulted in staff formulating care plans for patients without access to all the necessary and relevant patient information.
Recipients of PFD Report: An NHS Foundation Trust and the Secretary of State for Health and Social Care
Analysis: We have recently seen a number of PFD Reports issued for very similar reasons by Coroners across the country. There continues to be a systemic issue across the NHS estate regarding disjointed record keeping between healthcare providers. This often results in patient information being inadequately captured, or inadequately shared between the different care providers. Coroners continue to frequently issue PFD Reports in this regard, and it remains one of the most prominent themes arising at inquests for healthcare providers.
Healthcare providers should continue to identify early on any care, service, or delivery risks in a patient’s care. To mitigate the risk of being issued with a PFD Report, healthcare providers should demonstrate that appropriate action has been taken to safeguard patients from such risk.
If you have concerns regarding an upcoming inquest or would like advice on how to mitigate the risk of a PFD Report, please do not hesitate to contact a member of the team.
For further information, please contact:
Sofia Bradford, Hill Dickinson