Coroner's Duties To Prevent Future Deaths

• Author: Anna Naylor
• Law Firm: Weightmans
• Published date: 24 January 2023

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...