A Coroner’s Prevention of Future Deaths (PFD) report ought to be viewed as a critical learning tool, though it can also indirectly pose reputational challenges for organisations. When a PFD report is issued, the Coroner has concerns that matters identified during an inquest may lead to future deaths. The recipient of the report has a duty to respond within 56 days, detailing the steps taken to address the Coroner’s concerns. Failure to respond to a PFD report can lead to consequences beyond non-compliance – what the Chief Coroner for England and Wales refers to as a “badge of dishonour.”
Understanding Prevention of future Death (PFD) Reports
PFD reports, issued under Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, are a mechanism by which Coroners can raise concerns about ongoing risks identified during an inquest and a Coroner has a duty to write a report if a concern arises. These reports are designed to prevent future deaths by prompting organisations to review and amend their practices, policies, or systems.
The recipient of a PFD is legally required to respond within 56 days (Regulation 29(4)), outlining the actions they have taken or plan to take to remedy the issues raised, or explaining why no action is indicated (Regulation 29(3)). This response is not just a formality but a critical element of post-inquest accountability.
The Coroner must send a copy of the report and any response to the Chief Coroner and to all interested persons who the Coroner believes should receive it (Regulation 28(4)(a) and Regulation 29(6)). Upon receipt of a report, the Chief Coroner may publish a copy of the report, or a summary of it, in such a manner as they see fit (Regulation 29(7)(a)) which may include the Chief Coroner page on the Courts and Tribunals Judiciary website.
The “Badge of Dishonour”
The Coroner has no power to compel the recipient of a PFD report to respond and there is no oversight mechanism. However, the Chief Coroner for England and Wales, Her Honour Judge Alexia Durran, issued the following statement at an Insights Panel on 9 September 2024:
“I have decided to publish a list of those organisations who do not respond [to a PFD report]. That will be a badge of dishonour. It seems to me that if the Chief Coroner has to publish a prevention of future death report and any response, then if a response is not forthcoming this should be clear. So no longer will there be any suggestion that responses have not been uploaded [to the Chief Coroners website]. Going forward it will be clear that no response has been provided rather than simply an absence of response.”
As of 1 January 2025, the Chief Coroner will now publicly note any failure to respond to a PFD report, placing the organisation on a publicly accessible list. This list functions as a “badge of dishonour”, highlighting the organisations that have not engaged with the process.
Implications for Healthcare organisations
Being associated with a failure to respond to a PFD report could potentially be perceived as a lack of accountability, potentially undermining public confidence and leading to reputational damage.
In the healthcare sector, failure to respond could incite public scrutiny, attracting media interest and attention from regulatory bodies such as the Care Quality Commission (CQC) who may view non-compliance as a sign that further intervention is required.
A Coroner’s PFD report is an opportunity for organisations to demonstrate proactive engagement with safety concerns. A thoughtful, comprehensive response to a PFD report not only satisfies the legal requirement but also presents an opportunity for organisations to highlight their commitment to improving safety and care.
Mitigating the Risk
For organisations who have received a PFD report, two key steps can help to ensure compliance with the process.
- Internal Coordination: Organisations should ensure that the response to a PFD report involves all relevant stakeholders. Systemic issues may require input from multiple levels of leadership, clinical governance teams, and external advisers. A collaborative approach will lead to a more comprehensive and credible response.
- Timeliness: Meeting the 56-day deadline is critical. Upon receipt of a PFD report organisations should actively engage with the issues raised. Delays not only risk a ‘badge of dishonour’ but also suggest a lack of urgency in addressing potential safety issues. If more time is needed, seeking an extension from the Coroner can sometimes be an option, but this must be done proactively.
Conclusion
Failure to respond to a PFD report being perceived as a ‘badge of dishonour’ is a real and significant risk for organisations. However, with proactive engagement and a focus on collaboration, organisations can turn this challenge into an opportunity to demonstrate their commitment to safety and continuous improvement.
Hill Dickinson are experienced in advising and supporting organisations throughout the inquest process, including the preparation and submission of evidence to avoid a PFD being issued, and advice on effective PFD report responses.
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