Non-responses to Prevention of Future Deaths (PFD) reports

Written by Anna Lyp and Samantha Minchin

On 1 January 2025, for the first time, the Chief Coroner HHJ Alexia Durran published a list of organisations and individuals who did not respond to Prevention of Future Deaths (PFD) Reports in 2024. She called this a ‘Badge of Dishonour’ and stated that going forwards this report will be published annually. 

What is a Regulation 28/PFD Report? 

Following an inquest or investigation into a death, a coroner may issue a Regulation 28 PFD report, where they believe that action to address identified concerns should be taken to prevent future deaths. 

PFD reports are not intended to be punitive; their primary purpose is as a learning tool to bring concerns regarding public safety to the attention of the recipient. 

Organisations that receive a PFD report from the investigating coroner have a statutory obligation to respond within 56 days. Extensions can be requested from the issuing coroner but may not always be granted. 

How to respond to a PFD Report

Regulation 29(3) of The Coroners (Investigations) Regulations 2013 sets out how to respond to a PFD report. The response to a report must contain details, timescales and responsibilities in respect of any actions that have been taken or which will be taken whether in response to the report or otherwise. Alternatively, it must set out why no action is proposed.

Where a response contains confidential or sensitive information or may have a prejudicial effect on an ongoing investigation or legal proceedings, representations can be made to the investigating coroner about the release of part or all of the report. Subject to this, copies of all responses are sent to the Chief Coroner. The investigating coroner must also send a copy to interested persons (including the bereaved family). The Chief Coroner may publish the response and copy it to anyone who they think may find it useful. All PFD reports and responses released by the Chief Coroner are publicly available. 

2024 has produced a record high number of PFD reports: 681, compared to 547 in 2023.  From the statistics published by the Chief Coroner, it is apparent that 46 reports, constituting 15%, did not receive a response.

Failure to respond to a PFD report

Whilst recipients are legally obliged to respond to PFD report, the coroner has no power to compel a response, impose a sanction for failure to respond or comment on the adequacy of any response received.

However, with a a list of non-responses now published by the Chief Coroner, the recipients of PFD reports need to be more aware of the risks of a failure to respond. These may include the following:

• Reputational damage and increased public and media scrutiny;
• Greater oversight by individual coroners, which may in turn result in further PFD reports being issued to the same organisation;
• For healthcare organisations, being included on the list of non-responders may attract the interest of the Care Quality Commission (CQC), which may in turn engage its regulatory mandate and decide that a further intervention is required;
• For individual medical practitioners, individual regulators may perceive non-responding as departure from standards by its registrants. For example, doctors, physician associates (PAs) and anaesthesia associates (AAs) are regulated by the General Medical Council (GMC), which requires that its registrants must cooperate with formal inquiries; failing to respond to a PFD report may therefore constitute a departure from the GMC’s requirements and may result in a formal regulatory investigation and sanction.

Mitigating the risk of a PFD report being issued

The investigating coroner may not require a PFD report where an organisation has already implemented appropriate action prior to the inquest. In deciding whether to issue a PFD, the coroner will take into account the nature of the commitment to take action, any evidence in support of it, and an assessment of the organisation’s understanding and commitment to addressing the area of concern. 

Conclusion

Ensuring that a timely response to a PFD report is returned to the coroner is now more important than ever, with the added scrutiny of non-responses published by the Chief Coroner. On receipt of a PFD report organisations should co-ordinate key personnel and gather evidence promptly to ensure the 56 day deadline for a response is met.

An inquest can be an acutely stressful environment. Bevan Brittan works with organisations to prepare for an inquest and to minimise the risk of a PFD report being issued. Our inquest team is able to offer levels of support for an inquest tailored to its complexity. We have vast experience in representing organisations for inquests, including the NHS, local authorities, independent health and social care providers, fire authorities, housing providers, prisons, regulators, schools, universities and individual professionals.

If you would like support in relation to an inquest please contact Claire Leonard or Samantha Minchin.

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