Chief Coroner issues revised guidance regarding reports for the Prevention of Future Deaths

On 4 November 2020 the Chief Coroner for England and Wales, His Honour Judge Mark Lucraft QC, produced revised guidance for issuing reports to Prevent Future Deaths (PFD) in inquest proceedings having previously issued revised guidance on 14 January 2016 and on 4 September 2013.

For those of you who are unfamiliar with the role of the Chief Coroner he is head of the coronial system in England and Wales and provides national leadership for all coroners in this jurisdiction.

By way of background, a coroner will usually issue a PFD report where he or she has concluded an inquest hearing - the purpose of which is to ascertain who the deceased was, where, when they died and how and by what means and in some cases, in what circumstances. The coroner’s power to issue a PFD report is a “bolt on” jurisdiction which can be used where he or she has identified, as a result of the coronial enquiry, an ongoing risk that others might die in the same or similar circumstances as the deceased and that a person or organisation has the ability to take steps and introduce procedures that will reduce or eliminate that risk.

We can confirm (having compared the revised guidance to the previous version) that the approach to the issue of PFD reports by coroners remains unchanged. The revised guidance appears simply to be an update to the document given that the previous revised version was over four years old. 

The revised version does however, reiterate that PFDs are:

  • “...not intended as a punishment they are made for the benefit of the public.”; and
  • “Intended to improve public health, welfare and safety.”

If a health and care organisation or university is involved in an inquest, which is very often the case, the correct approach to dealing with the issue of PFD reports is to:

  • very carefully consider any findings following the completion of any separate internal or independent investigation, with particular attention being paid to any recommendations arising; and
  • adopt an early plan of action for the implementation of those recommendations if they are accepted. This needs to be supported by clear and cogent evidence of implementation which can be presented to the coroner in the inquest proceedings.  

At Mills & Reeve we have vast experience in dealing with inquests and advise on all aspects of the coronial process and proceedings, including how best to approach issues that may expose organisations to potential PFD reports in those proceedings. Organisations are reminded of the need to take early and obvious steps, which are within the power of an organisation, to reduce the risk of death to individuals as failure to do so can have serious financial, regulatory and reputational consequences. It should not be forgotten that inquests are public hearings at which the press can be and often are present.

If you would like to discuss any of the issues raised here or would like support with inquests please do get in touch with me or our inquest team.

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