INQUEST have launched their new campaign – No More Deaths – which seeks to challenge the lack of transparency, action and accountability for recommendations arising from state related deaths.

INQUEST are calling on the government to create a National Oversight Mechanism: a new independent public body responsible for monitoring recommendations arising from inquests, inquiries, official reviews and investigations into state-related deaths.

A National Oversight Mechanism would:

  • Collate recommendations and responses in a new national database

  • Analyse responses from public bodies and issue reports

  • Follow up on progress, escalate concerns and share thematic findings

Here at Farleys, we are supporting the campaign and would encourage you to sign the petition here.

The campaign is supported by over 40 organisations so far, such as JUSTICE, Liberty, Mind, Grenfell United and the Hillsborough Law Now Campaign. The need for a National Oversight Mechanism or similar type of body has been recommended by the Justice Select Committee, the Mayor of London and the Angiolini Review (2017).

You can read more about the campaign here.

Prevention of Future Deaths Reports

Public and private bodies have a duty to protect our lives, but every year hundreds of people die in their care, such as deaths of people in police and prison custody or in mental health settings.

Hundreds of vital recommendations are made following inquests and inquiries. A coroner has a legal duty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths. This is known as a ‘report under regulation 28’ or a ‘Preventing Future Deaths Report’.

The report is sent to the people or organisations who are in a position to take action to reduce the risk. They then must reply to say what action they plan to take.

However, there is no system in place to oversee the reports or ensure that changes are made in line with the responses. Potentially life-saving recommendations can be forgotten, dismissed, or not implemented.

Often families want to ensure that any lessons are learned following the death of a loved one and to ensure that the same thing will not happen to anyone else. INQUEST are calling for this change to help protect lives.

Farleys’ examples where Prevention of Future Deaths Reports have been made

Farleys’ inquest team have experience of a number of inquests where the Coroner has gone on to make a Prevention of Future Deaths Report following concerns that there is a risk of other deaths occurring in similar circumstances.


Earlier this month, the Area Coroner for Manchester City, Mr Zak Golombeck, issued a Prevention of Future Deaths report to the Secretary of State for Health and Social Care and the Secretary of State for Justice in the inquest into the death of GL. Concerns were raised around GL’s discharge under the provisions of the Mental Health Act 1983. The discharge was authorised under Nearest Relative Powers. Concerns include that the Nearest Relative Power may present an opportunity for a patient and/or their nearest relative to apply for discharge where the patient still meets the criteria for detention.

Rowan Thompson

In the inquest into the death of Rowan Thompson, Senior Coroner for Manchester North, Ms Joanne Kearsley, raised three issues in a Prevention of Future Deaths report to Greater Manchester Mental Health Trust (GMMH) and NHS England, including: the ability for paramedics to navigate the Prestwich Site; whether blood test forms had been changed to include the correct contact details between GMMH and NCA; and the lack of CCTV being checked for observations made by staff at the Prestwich Site. GMMH responded to confirm they are reviewing the use of therapeutic observations and engagement. On a national level, NHS England confirmed they are prioritising making improvements to mental health services and they have commissioned an Independent Review into services at GMMH. More information about the inquest conclusion can be found here.

Awaab Ishak

Following the inquest into the death of Awaab Ishak, Senior Coroner Ms Joanne Kearsley also made a Prevention of Future Deaths Report to the Department for Levelling Up, Housing and Communities and the Secretary of State for Health. They responded to confirm that they agreed with the Coroner’s concerns and that they expect social housing providers to learn lessons from this death and ensure landlords understand the risks of damp and mould and act swiftly when necessary. You can read more about Awaab’s inquest here.

If you’re looking for representation at an inquest following the death of a loved one, please get in touch with Farleys’ inquest specialists on 0845 287 0939, contact us by email, or use the online chat below.