Coroner's Duties To Prevent Future Deaths

• Published date: 24 January 2023
• Subject Matter: Food, Drugs, Healthcare, Life Sciences
• Law Firm: Weightmans
• Author: Anna Naylor

When is it deemed necessary for the coroner to issue a Prevention of Future Deaths report?

Whilst the key focus of any inquest is typically the question of 'how' a person came by their death, for many interested persons involved, a central concern is whether or not the coroner will issue a Prevention of Future Deaths report, (PFD report), to seek to ensure that changes are made to prevent further deaths in the future.

PFD reports are made pursuant to paragraph 7(1) of Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. A coroner has a statutory duty to act and produce a report where:

1. A senior coroner has been conducting an investigation into a person's death, (this will normally be after an inquest has concluded, but not necessarily); and
2. After considering all the documents, evidence, and information something is revealed within the investigation which gives rise to the coroner having concerns that future deaths will occur, or will continue to exist, in the future; and
3. In the coroner's opinion, action should be taken to prevent those circumstances happening again or to reduce the risk of death created by them.
   If all three of the above apply, then the presiding coroner must notify the matter in a PFD report to a person or organisation who the coroner believes may have the power to take such action required. As such, these reports are an important mechanism to improve public health, welfare, and safety.

Practicalities of issuing a PFD report

The Chief Coroner's Guidance No5 makes it clear that is not for a coroner to make recommendations as to what specific action should be taken, but simply to draw attention to any areas of concern for the person/organisation to consider. A PFD report does not have to be limited to matters which are causative of the death in question.

The recipient of the PFD report must then respond in writing within 56 days of receipt setting out the action that has been taken, is proposed to be taken or, alternatively, must set out why no action is proposed. It is also worth noting that all PFD reports and responses are available to the public on-line and, in addition, the coroner will also send them to any other interested persons who may find them useful or of interest.

So, whilst PFD reports are not intended to be a punitive measure, the issue of a PFD report can have far-reaching effects not only in terms of the resources required to respond to it but...