After an inquest, coroners can issue Prevention of Future Deaths (PFD) reports to an organisation, local authority, government agency or person in an attempt to stop similar losses of life. The changes advocated by coroners are not legally enforceable as bodies are not under a legal duty to respond and there are no sanctions if they do not comply.

The Independent Advisory Panel on Deaths in Custody (IAPDC) state that the preventative potential of PFD reports is not being realised with families criticising the system as “nothing more than a paper exercise”.

The panel has found that PFD reports vary greatly in quality, are published long after the issue in question has been identified and may not be sent to the organisations best placed to ensure that changes are made thus limiting their potential impact.

The IPADC in support of the charity INQUEST have made a number of recommendations to unlock the preventative potential of PFD reports by encouraging coroners and the parties concerned to see these reports as an opportunity to improve, share good practice and ultimately prevent custodial deaths – not as criticism to be avoided at all costs.

Additionally, the IAPDC has suggested that the government set up a new body to audit and produce a yearly review of PFD reports for custody deaths which should identify themes and trends and report on the timeliness and quality of responses.

Deborah Coles, former panel member and executive director of the UK’s charity INQUEST commented –

“families go through protracted and complex inquests after deaths in detention in the hope that no other family will go through the same experience and that positive changes occur, yet time and time again, we are seeing repeated patterns of failure which contribute to these often preventable deaths”.

Ms Coles went onto state that “we need to maximise the preventative potential of these reports that too often simply gather dust”.

In May 2023 the Office for National Statistics published qualitative analysis on PFD reports for suicide submitted to coroners in England and Wales between 2021 and October 2022. The aim was to identify themes from concerns raised in the reports that may inform future research or policies for suicide prevention.

A total of 164 PFD reports were available and the key stats identified from the analysis are:

    1. A total of 485 concerns were identified with an average of three concerns per report;
    2. Of the 164 reports, around 62% of the deceased were male, 37% were female with the remaining genders unknown;
    3. The average age at date of death was 36.4 years.
    4. The NHS (including health boards, trusts, clinical commissioning groups, primary care services, health and care partnerships and ambulance services) were the most frequent recipient organisation of PFD reports, followed by government departments.


The coroners concerns were codified into 12 primary themes. Notably, coroners were concerned with inadequate monitoring and documenting of processes, access to services, assessment and clinical judgement, policy and communication.

Here at Farleys, our specialist inquest solicitors have represented clients in a number of inquest cases, be they deaths in prison or police custody, deaths in medical care or otherwise private inquest cases.

It is important that your concerns surrounding the death of your family member are appropriately addressed. We understand the distress and anguish that a death of a family member can cause. We can provide advice, assistance, and representation to ensure that you are fully supported throughout such a difficult time.

If you require representation at an inquest, please contact our team on 0845 287 0939 or complete our online contact form.