On 1 January 2025 the Chief Coroner for England and Wales, HHJ Alexia Durran, published a report listing all organisations and individuals who failed to respond to a Prevention of Future Deaths (PFD) report in 2024. Labelling this a ‘badge of dishonour’, this is the first time in history that a Chief Coroner has introduced this scrutiny in an attempt to increase accountability for organisations and individuals that fail to respond. The Chief Coroner has confirmed this will be done annually moving forwards.
Surprisingly, out of the 37 bodies called out in the Chief Coroner’s report, 17 operate in the healthcare sector. This includes various health boards, providers of health and social care, as well as regulators and other bodies and associations that operate in the sector.
In this article we provide a brief summary of the purpose of PFD reports within inquests and what recipients of PFD reports are required to do. We also consider how organisations and individuals can avoid being the recipient of a PFD report, what should be included in a response to a PFD report, the risks that come with failing to respond, and what it means for organisations going forward, now that organisations and individuals will be named and shamed for a lack of response.
An inquest is an investigation led by a coroner into a death that isn't immediately explainable. In particular, it's conducted when someone has died suddenly, violently or unnaturally, died while in state custody, or when the cause of death remains unclear after a post-mortem examination.
Section 5 of the Corners and Justice Act 2009 confirms that the primary purpose of an inquest is to answer four statutory questions - who the deceased was, and when, where and how they died. They are inquisitorial proceedings to establish facts, and whilst it's inevitable that potential failings of organisations or individuals may be identified during the process, inquests do not seek to allocate any blame or responsibility for a death, or to establish any criminal or civil liability of the parties involved.
A coroner will appoint 'interested persons', organisations and individuals with a sufficient interest in the inquest, to participate in the proceedings. During this process they will gather evidence, and will obtain and hear witness testimony during the process. Whilst no criminal or civil liability will be established, a conclusion will be drawn about the deceased’s cause of death and this will be recorded in a Record of Inquest.
There are a range of ‘short-form’ conclusions that can be can reached, including:
Alternatively, if a short form conclusion doesn't satisfactorily record the circumstances of a death, a narrative conclusion may be reached. This allows a brief factual description of the circumstances by which the death came about.
It should be noted there is also the possibility for a rider of ‘neglect’ to be attached to an inquest conclusion, when it's considered that the deceased’s death was contributed to by the gross failure of an organisation or individual to provide the deceased with basic medical attention or necessary care e.g. ‘natural causes contributed to by the neglect of…’
Pursuant to Regulation 28 of The Coroners (Investigations) Regulations 2013, a coroner presiding over an inquest has the power to issue what is known as a PFD report at any point during the process. In fact, they have an obligation to do so if during their investigations they become concerned that circumstances creating a risk of other deaths will occur, or will continue to exist in the future, unless action is taken to prevent this. These concerns tend to arise when a coroner identifies systemic issues that require change within an organisation or system.
In a PFD report a coroner will set out their concerns and will make recommendations to the recipient to take action to ensure that lessons are learned and that appropriate changes are made to policies and procedures, so that future deaths arising from similar circumstances do not reoccur.
PFD reports are published on the Judiciary website and can be accessed by the wider public and media. This can have huge reputational consequences for recipients, particularly as the report in identifying matters of concern, will often draw attention to internal failings in an organisation’s systems and practices. In some circumstances, the criticisms raised in a PFD report can also be the subject of scrutiny by regulatory authorities such as the Health and Safety Executive or Care Quality Commission. In light of this, organisations and individuals who find themselves involved in an inquest, need to be aware of the risk of a PFD report being issued and take steps to minimise this risk.
A crucial step to help mitigate against a PFD report being issued is evidencing that steps to prevent a similar incident have already been taken, or are at least have been identified and changes are in the process of being implemented. From the outset, organisations and individuals involved in a death should think about conducting a review into the incident and where any failings or learning are identified, should consider implementing appropriate and meaningful actions to address these as soon as possible. Where this commitment can be illustrated, a coroner is more likely to feel assured that any identified issues and concerns are in hand and that a PFD report isn't required.
Recipients of a PFD report are required, by regulation 28 of The Coroners (Investigations) Regulations 2013, to provide a response with 56 days. There is no specific format for a response but the regulations provide that the response must include:
It should be noted that a coroner does not have any power to force a response to a PFD report, and cannot issue any sanctions for a PFD recipient’s failure to comply with the duty to respond.
Nevertheless, with the Chief Coroner’s decision to publicly call out those who fail to respond, there are now increased risks posed to recipients going forward. For example, failing to respond and being named and shamed for this could lead to greater media scrutiny, as a lack of response could be interpreted as a recipient failing to take the coroner’s concerns seriously and to accept accountability. If this is reported on, it could lead to severe reputational damage and a loss of public confidence.
It's somewhat surprising that almost half of the recipients called out for failing to respond to a PFD report in 2024 are linked with the healthcare sector and this includes a number of public bodies and public corporations. Whilst these bodies may face no punishment from the coroner, the organisations who failed to respond who are regulated, may risk further scrutiny from regulatory bodies such as the Health and Safety Executive or the Care Quality Commission.
In the event that a healthcare organisation is subject to an inquest and receives a PFD report, it's now more important than ever that a timely response is provided within 56 days. This will ensure that the organisation doesn't receive the Chief Coroner’s ‘badge of dishonour’ and expose itself to the abovementioned risks.
It's essential that if a PFD report is received by an organisation during the course of an inquest, a team of key individuals are allocated to gather the necessary evidence and formulate the response, ensuring that key stakeholders have input where required and that legal advice and support is sought where necessary.
It should also be noted that where healthcare organisations are subject to an inquest, steps should be taken from the outset to mitigate against the risk of receiving a PFD report in the first place. If it can be illustrated that appropriate actions have already been implemented to address identified failures and learnings have, a coroner may feel assured that a PFD report isn't necessary.
For further information, please contact the business risk and regulation team.
