The Office for National Statistics published qualitative analysis on Prevention of Future Death reports for suicide submitted to coroners in England and Wales between January 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.

What is a Prevention of Future Death Report?

Coroners can issue a Prevention of Future Death (PFD) report to individuals and organisation where they feel action should be taken to prevent future deaths. The role of the coroner is to identify areas of concerns, rather than specific solutions.

PFD reports are sent to a wide range of organisations, including the NHS, government departments, professional bodies and public services. The report is also sent to the deceased’s family.

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

  • A total of 485 concerns were identified with an average of three concerns per report;

  • Of the 164 reports, around 62% of the deceased were male, 37% were female with the remaining genders unknown;

  • The average age at date of death was 36.4 years.

Addresses by Organisation Type

The NHS (including health boards, trusts, clinical commissioning groups, primary care services, health and care partnerships and ambulance services) was the most frequent recipient of organisation of PFD reports. This was followed by government departments.

Coroners’ Concerns

The Office of National Statistics coded the coroners’ concerns into 12 primary themes, this blog will focus on the most frequently mentioned concerns.


A total of 142 concerns from 89 PFD reports related to “processes” with “inadequate monitoring and documenting of processes” being the most common sub-theme. This sub-theme related to processes not being recorded or standard operating procedures not being following, thus potentially contributing to a death.

Access to services

There were 84 concerns relating to “Access to services” in 52 PFD reports. Sub-themes included “delays in accessing services” (21 mentions), “inadequate staffing (17 mentions) and “services not being appropriate” (16 mentions).

Assessment and clinical judgement

There were 78 concerns relating to “assessment and clinical judgement” in 55 PFD reports. Risk was not correctly assessed where patient history was not considered or communication between services was poor, preventing the patient from receiving appropriate treatment.


There were 77 concerns under “policy” in 45 PFD reports. Sub-themes included “no policy in place (processes)” (16 mentions), and “inadequate policy” (12 mentions).


There were 55 PFD reports including 68 concerns relating to “communication”. Sub-themes included “inadequate communication between services”, meaning information involving the patient was not communicated which may have contributed to failures in care.


There were 50 concerns from 30 PFD reports related to “training”. Sub-themes included “current training not adequate”, that referred to staff training not being mandatory, training not sufficiently covering a topic, training not being applied in practice, or training not being updated following incidents.

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.