Inquests, reports to prevent future deaths and the “badge of dishonour”
The Chief Coroner’s new “Bench Book”, published on 1 January, covers all aspects of court inquest work, including a chapter on reports to prevent future deaths (PFD). You can read our earlier blog on the new guidance here.
The Chief Coroner, Her Honour Judge Alexia Durran, has also published on 1 January a list of those organisations who have not responded to a PFD report in 2024, which she refers to as a “badge of dishonour”. This is the first time the Chief Coroner has published such a list. You can view the list on the Courts of and Tribunals Judiciary webpage.
It's of note that of the 36 organisations listed, 16 are involved in the health and care sector from commissioners to providers, regulators and professional bodies.
Here we provide a summary of the purpose of PFDs and what recipients of PFDs are required to do.
What is a Regulation 28 or PFD?
When investigating a death, a coroner must issue a PFD when they consider there is a risk of other deaths occurring, and that action should be taken to prevent or reduce the risk of future deaths. Those individuals/organisations that receive a PFD are then under a duty to respond.
PFDs are also known as “Regulation 28 reports”, as Regulation 28 of the Coroners (Investigations) Regulations 2009 provides detail on the PFD process.
A PFD cannot be made until the coroner has considered all the information that is relevant to the investigation. In our experience, coroners generally wait until the end of an inquest before making a PFD. While there is no requirement in law to give a likely recipient of a PFD the opportunity to make representations before one is issued, this may be considered appropriate by the coroner.
While a PFD should identify concerns and suggest action, it is not for the coroner to recommend particular action or give a view on what that action should be.
A PFD should usually be sent within 10 working days of the end of an inquest, to a person/organisation who the coroner believes may have power to take such action.
Responding to a PFD
A response to a PFD must be provided within 56 days, unless the coroner agrees to an extension. There is no template for a response, but it must include either:
- The details and timetable of any action taken or proposed.
- An explanation as to why no action is proposed.
The response may be sent to other interested persons in the inquest by the coroner. The response will usually be published, but it is possible to make written representations to the coroner about the release of the response or its publication.
There is no power to withdraw a PFD once it has been served, even if it was based on a misunderstanding. If an organisation considers a PFD should not have been made, the appropriate action is to respond explaining why no action will be taken.
If no response is provided to a PFD, or the coroner considers the response to be inadequate, there are limited further steps that can be taken by the coroner, because once a PFD is made, the coroner has completed their functions in respect of that PFD.
The Bench Book confirms that where the facts at the time of the death would have given rise to a PFD, but action has been taken before a final inquest hearing to remedy those issues, it is difficult to see how a coroner could make a PFD, as the preconditions (set out above) will not be met.
Comment
Ensuring your organisation responds to a PFD is now more important than ever, with the added layer of scrutiny of non-responses to PFDs published by the Chief Coroner.
If your organisation requires support with an inquest or receives a PFD, do get in touch with us. We can support you with your response and actions to mitigate against the risk of receiving a PFD.
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