Effect of the Chief Coroner’s revised guidance on reports to prevent future deaths

On November 4 2020, the Chief Coroner issued revised guidance on the issuing of prevention of future deaths (PFD) reports. While the law has remained unchanged by the recently revised guidance, there are some notable changes that our healthcare clients should be aware of.

PFD reports as a learning tool

The underlying purpose of a PFD report is to be used as a learning tool for future cases. The revised guidance stresses that PFDs should not be punitive, but are instead ‘intended to improve public health, welfare and safety’. 

Consideration of remedial action already taken

The revised guidance seeks to clarify whether a PFD report is necessary if corrective action has already taken place, or if there are robust plans in place to address issues already raised. The Chief Coroner advises that when deciding whether to make a PFD report, coroners should consider the position of the organisation at the end of the inquest, i.e. whether appropriate action has already been implemented by the body. This may avoid unnecessary PFD reports.

If action has not yet been taken, the revised guidance states that coroners must take into consideration the organisation’s commitment to taking action. If a coroner is unable to recognise commitment to implement change, they may be more likely to issue a PFD report. 

Local considerations

The revised guidance stresses the importance of local context when considering whether to make a PFD report. This means that a coroner can now consider other PFD reports that have been made to the same organisation. Healthcare operations need to be very aware of this and ensure that they are doing all they can to address any issues identified in PFDs. Organisations that have been slow to implement change, or that have already received a similar concern, may be more likely to be issued with a PFD report. 

Issues not explored at inquest

The guidance emphasises that coroners should be wary of issuing PFD reports on matters that were not properly explored at inquest. 

Challenging a PFD

The revised guidance explains that once a PFD report has been submitted, it cannot be withdrawn. It remains that in order to challenge a PFD report, a written response must be issued within 56 days.

Alternatives to PFD reports

There may be circumstances where a coroner wishes to raise a concern but is not duty-bound to issue a PFD report. This may be because the concern is not related to the prevention of future deaths. The revised guidance stresses that letters should only be issued in exceptional circumstances.

Formatting of PFD reports

The revised guidance also provides a framework for PFD reports to ensure consistency of drafting. Several more examples of PFD reports have been published in the revised guidance. Having a common objective reiterates the primary aim of the revised guidance: to drive change and learn from deaths.

Receiving a PFD report

PFD reports can highlight concerns about how organisations operate which can lead to increased scrutiny. Receipt of a PFD report can have serious financial, regulatory and reputational ramifications for any organisation. 

While it is important not to forget the basics, i.e. taking every possible step to avoid deaths in the first instance, we recommend the following steps when in receipt of a PFD report:

1.    Thoroughly review the findings of this PFD report
2.    Accept and identify any reasonable recommendations – remember that these reports are intended to improve public welfare
3.    After investigation, promptly make any accepted changes that are recommended by the report, or at the very least set out robust plans to implement the recommendations as soon as reasonably possible. Supporting evidence of the implementation plan is crucial to satisfy the coroner
4.    Be cognisant of any timescales that have been set/recommended by the coroner
5.    Consider regular internal investigations in an attempt to mitigate future failings. Compile and distribute any evidence gathered to further enhance learning within the organisation

How Lockton can help

We offer policies that provide robust assistance to practitioners and organisations going through the challenging experience of an inquest. We are always at the end of the phone to provide practical, empathetic and straightforward advice. As soon as notice of a patient death is received, we ensure that the wheels are set in motion to investigate what led to the death, and whether you as an individual or an organisation contributed to the death in any way. We assist with this by making sure that witness statements are obtained immediately, and offer practical and emotional support to those making the statements. 

Lockton offers guidance on the Serious Incident (SI) investigation process, and can help to coordinate internal clinical commentary and ‘lessons learned’ data, as well as instructing appropriate external law firms at the outset in especially complex cases. Where required, we obtain early expert opinions and barrister views, ascertaining whether an admission of liability is required (if it is, it can mean a lot to the family and loved ones of the deceased). An admission of liability can also accelerate the learning process while significantly reducing the possible costs that could otherwise be recovered in civil proceedings.

Through our relationship with leading clinical negligence and inquest law firms, we ensure that you have the most experienced, erudite and insightful representation at inquests to guarantee that a PFD is only issued where required. If and when you do find you are issued with a PFD, we are here to help you to examine it and implement the recommendations as part of our risk management service as your dedicated healthcare services broker. We can also help you to manage the timeframes associated with making such changes, and we offer dedicated training and ‘lessons learned’ sessions in order to ensure that learning is disseminated through your organisation as appropriate.

If you would like further information, please feel free to contact us using the details below.


Flora McCabe
Head of Healthcare Claims
Senior Vice President 
0207 933 2516


Laura Blundell 
Account Manager
0207 933 1217  
07770 833 030


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