RWK Goodman: Prevention of Future Deaths Reports

Inquests are fraught with legal technicalities and potential pitfalls – one very serious one being the risk that the coroner will issue what is known as a prevention of future deaths report (PFD).

What is a PFD?

If the coroner is concerned that future deaths may occur if something is not changed, they are required to issue a prevention of future deaths report. These reports are published online and require a response (within 56 days) setting out what action has been taken, is going to be taken or an explanation if nothing is going to be done.

Recent PFD’s have raised issues that were not necessarily central to the inquest – such as unclear policies, poor audits and poor record keeping.

Impact of a PFD

In addition to the obvious detrimental impact on a service’s reputation, a PFD can require time and money be spent in investigating, analysing and amending procedures. It can also attract unwanted attention from regulators such as CQC.  When there is a death in a service, there can also be a risk of a health and safety prosecution by CQC, as well as civil compliance action.

Can they be avoided?

It might not be possible to avoid a PFD altogether but there are steps that can be taken to mitigate the risk of one being issued by the coroner – proper preparation is key!

The first step is to undertake a proper investigation and analysis of the incident – evidence of that can help reassure the coroner that there is little risk of the same incident happening again.

The second is identifying who should provide evidence and ensuring that their written evidence is clear, strong and exhibits the relevant documentation. It may be appropriate to submit a witness statement from a manager or director addressing the wider issues as well as from those ‘on the ground’.

Witnesses should be well prepared for the inquest in the event that they are called to give live evidence. They should be familiar with their own evidence, the other evidence that is before the coroner and they should be prepared to be questioned.

Conclusion

Early identification of the potential risks faced in an inquest and proper preparation is essential in dealing with the matter.

The Health and Social Care Team at RWK Goodman provides expert support to care providers in preparing for and dealing with inquests. We can help not only with an inquest, but with managing the wider set of potential regulatory and other ramifications that flow from them.