Also known as ‘Regulation 28 Reports’, coroners in the UK can issue Prevention of Future Deaths (PFD) reports to government departments, NHS health trusts, care agencies, and local councils upon the conclusion of an inquest, where it has been found there have been failings on part of the government department which have led to the death of an individual in their care.
The reports are mechanism by which coroners can raise concerns about ongoing risks identified throughout an inquest, the nature of which can encompass a wide range of issues on a systematic, procedural or policy level.
Coroners have issued PFD Reports on a number of matters dealt with by Farleys Solicitors, including in the cases of Charlie Millers, Awaab Ishak, Roman Thompson, and Oliver Davies.
The reports are designed to prevent future deaths of other individuals under the same or similar circumstances, by prompting authorities to review their practices and make changes where required. As the Chief Coroner’s guidance states, these reports are “vitally important if society is to learn from death”.
The reports also play an important role of reassuring families that the failures leading to the death of their loved one are reported, taken seriously, and responded to appropriately.
The issuing of a PFD report bears no power or authority to order anyone to take action, but the recipient has a duty to respond within 56 days, and the reports are published online alongside the responses received.
Prevention of Future Deaths Reports Unanswered
New figures show that in 2024, 12 PFD reports were unanswered by the responding authorities. The Independent Office for Police Conduct, South West London and St George’ Mental Health NHS Trust, National Highways, and the Health and Safety Executive were among those who failed to respond to Prevention of Future Death Reports issued to them.
Matthew Braben was a gentleman who died by suicide in August 2021 at HMP Wormwood Scrubs. The inquest into his death detailed a plethora of failings in his care, notably finding that that ‘no action’ was taken by the prison when concerns for Mr Braben’s mental health were raised by his family.
It is understood the lack of a response to the coroner’s concerns in his case is now being looked into, but the problem magnifies a wider issue – that concerns are not being taken seriously by authorities as and when they are reported. For bereaved families, the pain of unanswered questions relating to their loved one’s death remains a central part of their life. The opportunity of bringing about change following the death of their loved one through PFD reporting is just one way for families to navigate their grief and honour their loved one.
To this end, there is currently no formal system in place to oversee the responses to and changes made via Regulation 28 Reports.
The charity INQUEST have launched a national campaign calling for a National Oversight Mechanism to monitor and manage collating, analysing and following-up on recommendations arising from inquests, inquiries, official reviews and investigations into state-related deaths.
INQUEST state that a “lack of transparency, responsibility and accountability for recommendations has serious implications for bereaved families.” And highlight in their campaign that the lack of any monitoring system “undermines public trust in the UK’s investigatory framework, and has a significant human and financial cost.”
Legal Representation at Inquest
Our dedicated team at Farleys are equipped to guide you through the inquest process and the complex issues which may arise.
If you would like to discuss inquest representation, please get in touch with us on 0845 287 0939, contact us by email, or use the online chat below.