A new report from the Independent Advisory Panel on Deaths in Custody (IAPDC), More than a paper exercise – Enhancing the impact of Prevention of Future Death Reports finds that the preventative potential of PFDs is not being fully realised, with families criticising them as “nothing more than a paper exercise”’. With support from the Chief Coroner’s Office, the IAPDC launched a project to identify proposals for reform to improve the impact of this coronial function.
Coroners have a duty to issue a PFD to individuals and organisations where he or she feels action might need to be taken to prevent future deaths. As the Chief Coroner’s guidance states, these reports are “vitally important if society is to learn from death”. However, the IAPDC has found that their potential to identify future risks that might cause death in the future is not being fully realised.
Some issues raised by the IAPDC in its report were:
- PFDs varying significantly in quality.
- PFDs being published long after the issue in question has been identified.
- A lack of central research / analysis on which organisations can rely to draw trends and themes from PFDs over time.
The IAPDC makes 18 good practice recommendations for:
- Government departments, agencies, and private providers (recommendations 1-10)
- For the Chief Coroner and his Office (recommendations 11-14)
- Other bodies with a key role to play in preventing custody deaths (recommendations 15-18)
They call for an open and non-defensive approach being taken to PFDs. The IAPDC highlights that the public interest in preventing future deaths should be prioritised over reputational considerations, and all parties approach the PFD process with full candour and relevant information should be provided at the earliest appropriate opportunity. The IAPDC also makes recommendations around increased resources and funding to identify trends and themes emerging from PFDs.
Training and support
If your organisation requires support with an inquest or the management of a PFD report, please do not hesitate to get in touch.
The training and experience of staff has never been more important both in managing inquests, handling investigations, and putting action plans into practice. We can run sessions for your team, bespoke to your organisation’s needs. Contact us and we can talk about what would work best for you.
This blog post was written with support from Supriya Sriprasad.
Our content explained
Every piece of content we create is correct on the date it’s published but please don’t rely on it as legal advice. If you’d like to speak to us about your own legal requirements, please contact one of our expert lawyers.