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Focus on prevention of future deaths reports

What can we take away from the various PFDs issued by coroners in relation to patient care?

A Regulation 28 Report under The Coroners (Investigations) Regulations 2013, or Prevention of Future Deaths Reports (PFD reports) as they are known in short, are made by coroners to address issues arising from an inquest and can provide a powerful force for change. So, what can we take away from the various PFDs issued by coroners in relation to patient care? And, how do these help with wider learning?

To help with this, we have been studying the healthcare-related PFDs published on the Chief Coroner’s website for the past 6 months. We reviewed 306 reports in total. This exercise has helped us to see if any common themes emerge and to understand the landscape of how these fit into the wider learning from deaths nationwide. It is important to note that PFDs under the old statutory regime (pre-2013) were made at the coroner’s discretion, whilst coroners are now under a duty to make a report where a concern is identified.


Coroners have a statutory duty to issue a PFD report to any person or organisation where, in the opinion of the coroner, action should be taken to prevent future deaths. A copy of the PFD report is sent to the deceased’s family and is made available for anyone to read on the Chief Coroner’s website. Of particular importance to healthcare providers is that a copy of the report is also sent to the CQC so will lead to regulatory interest and could later trigger an inspection. In that respect, providers would generally rather avoid a PFD report, even though they can be useful from a learning perspective. Responses to some PFD reports are also published on the Courts and Tribunals Judiciary website, making them publicly available.

Our review of the Chief Coroner’s website has helped us identify what recurrent themes there are and in particular, what issues are triggering this coronial duty. It has also helped classify the geographical areas with the highest number of reports published. We found that the areas of East London, London Inner North and Greater Manchester South produced the most PFD reports with 57 out of the 306 reports deriving from these geographical areas.


Failure to recognise/escalate patients who were becoming critically unwell

A large percentage of the PFDs we reviewed had a failure to recognise or escalate patients who were becoming critically unwell. This can be seen specifically in respect of patients who have suffered falls and undergone complex surgery.

Another related issue is one of supervision by staff in relation to patients at risk of falling. A recurrent theme is that of a failure to provide adequate supervision to those patients at risk of falls and therefore the patient has fallen, sometimes multiple times, whilst in hospital. Patients not being correctly assessed and warranting a higher level of supervision, is another common theme.

Investigations not being completed on time

A further recurrent theme is that of timeliness of internal investigations and staff not seeing the outcome of these investigations in order to learn from them. This is particularly important in light of the revised PFD guidance No. 5, issued in November 2020, which has an increased focus on the underlying purpose of PFDs, which is to learn lessons from deaths.

Issues such as providers not completing investigations within a set period as per their policies and CCG expectations was a further issue of concern. One coroner commented that this was “obviously not acceptable and could put others at risk by a potential failure to learn”.

It is important to note that robust internal investigation systems and reports should help to reassure coroners and bereaved families that action is already being taken to minimise future risks, without the need to issue a PFD report.

Concerns over guidance and training for sepsis

Particular issues in relation to sepsis centre around guidance and training. Issues such as providers not having up to date guidance reflecting NICE guidelines, training for sepsis not being mandatory and delivered by doctors with relevant experience of current research and guidance, and contrasting opinions indicating a degree of confusion by senior staff have been highlighted as posing a threat to patients. It is clear that many coroners feel there is more that needs to be done in this area.

Risk management and planning for discharge

Risk management and planning for discharge is a recurrent theme amongst all of the healthcare-related PFDs, but particularly within the mental health cases. Coroners are very critical when there has been a failure to provide enough or adequate information on discharge. Issues of both documentation and communication between staff on the wards have been raised.

Specific issues in this area have been no name of the lead practitioner/primary contact responsible for providing support to the patient following discharge; parents not being made aware of their loved one’s discharge so not able to provide the appropriate support, and failure to complete adequate risk assessments and incorrect care planning for when patients leave wards/are discharged.

Concerns over care and treatment provided in maternity wards

Coroners are becoming increasingly concerned over maternity wards being operated in a safe manner. Criticism has arisen where providers do not have clear guidance to support staff and facilitate better outcomes.

Other related issues have been a requirement for regular reviews from another midwife or obstetrician and patients not being properly informed of birth plan options (specifically elective C- sections).

What have we learnt?

The events of the past year have put providers under a considerable amount of pressure and 2021 is likely to see a stronger than ever focus on how healthcare providers learn from deaths.

Going forward, it will be vital for providers to ensure, and therefore be able to demonstrate to the coroner (and families), that any potential failings in systems/care connected with a death are properly investigated and that actions taken/improvements made can be properly evidenced.

These themes have stood out as consistent issues for coroners nationally. It is important to note, however, that they usually form part of a longer list of issues and it is crucial that providers address them all.

Weightmans has a large national team of regulatory solicitors who specialise in advising and supporting healthcare providers across the health and social care sector throughout the inquest process.

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