Coroners' prevention of future death reports on the rise

Andrew Berkley, Senior Coroner for Staffordshire and Stoke-on-Trent, has requested £210,000 in extra funding for the county. With this extra funding, the Coroner wants to recruit a full time area Coroner and a part time personal assistant, with the aim to combat a “record number of cases” where families and loved ones have waited at least a year for the inquest process to conclude. Mr Berkley has described a familiar situation to those involved in inquest matters nationwide, being a rise in complexity and length of many inquests, putting more pressure on Coronial services and contributing to delays for families and loved ones involved in the process. If Mr Berkley’s request is successful, this could see a regional uptick in the number of complex inquests being listed and heard, and it could set a wider nationwide precedent in other requests for additional funding for other Coronial patches.

This comes following some BBC research stating that in 2023 109 Prevent Future Deaths (PFD) reports were sent to health bodies in 2023, these reports highlighted long NHS waits, staff shortages or a lack of NHS resources. The figure (all linked in some way to NHS pressures) was the highest figure of its kind in the past six years and is a huge increase upon the 59 reports drafted for similar issues in 2019.

An upward trend in PFD reports being issued largely as a result of NHS service pressures will likely see NHS bodies seeking more input from law firms to prepare detailed organisational learning evidence in an attempt to mitigate against the risk of a PFD report being drafted. In turn, this can legitimately lengthen inquest hearings and add to the complexity of issues being explored but can ultimately serve to reassure families and Coroners alike of the extent of lessons learnt and changes made by NHS bodies following a death.

Our inquest team has extensive experience in working with NHS bodies to prepare detailed organisational learning evidence, to sit alongside Patient Safety Incident Investigation, Root Cause Analysis or other internal investigation reports, to present to the Coroner during complex inquests.

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