Inquests are public inquiries conducted by a Coroner to determine the “who, when, where, and how” of an unexplained death. A crucial aspect of these inquests is whether the Coroner will issue a Prevention of Future Deaths (PFD) report, also known as a Regulation 28 report.

A Coroner is obligated to issue a PFD report under the following circumstances:

  1. The Coroner has been investigating a person’s death.

  2. The investigation reveals concerns that certain circumstances pose a risk of other deaths occurring or continuing to exist in the future.

  3. In the Coroner’s opinion, action is required to prevent these circumstances from continuing, or to eliminate or reduce the risk of future deaths caused by them.

The Role and Impact of PFD Reports

The recipients of a PFD report—often police, prisons, and healthcare institutions—must respond within 56 days, detailing the actions taken or proposed in response to the report or explaining why no action will be taken. These responses, along with the PFD report itself, may be published and shared with relevant interested persons and others whom the Coroner believes would benefit from the information.

From the perspective of interested persons, PFD reports are designed to enhance public health, safety, and welfare through quantitative and qualitative data. They are vital tools for highlighting systemic issues, some of which may lead to policy changes and reviews. We have experienced firsthand the repeated occurrence of similar deaths and the lack of effective measures to mitigate these risks. Currently, there is no formal or systematic approach at the local or national level to address these concerns comprehensively.

INQUEST, has called for the creation of a new independent body to audit PFD reports annually. This body would ensure that recommendations are implemented, addressing the accountability gap that currently exists.

According to the BBC, approximately 450 PFD reports were sent to health bodies and the government in England and Wales last year. These reports highlighted issues such as long NHS waits, staff shortages, and lack of NHS resources. At Farleys, we have represented a number of families over the past few years, resulting in the issuance of PFDs.

Examples of Inquests Resulting in a Prevention of Future Deaths Report

Nichola Lomax

Nichola Lomax suffered from one of the most serious eating disorders professionals had ever seen.

The Inquest found gross failures in the provision of basic care afforded to Nichola when she attended Fairfield A&E, failures in admitting her to hospital for a period of medical stabilisation, a lack of basic dietic advice, lack of clarity as to the treatment plan, poor nursing input, support and monitoring including a failure to complete nutrition and fluid balance charts and a lack of understanding around the input required from psychiatry.

The Coroner concluded that on the balance of probabilities all of the above failings probably caused or contributed to Nichola’s death.  Further, that over and above any clinical failures there has been a failure ensure there are appropriate pathways in place across the NHS in respect of MARSIPAN and a there was an absence of understanding for many clinicians as to where or how they can access specialist advice.  This was exacerbated by a failure to commission and provide a fully supported Community Eating Disorder Service across areas in Greater Manchester including Bury or to commission any Liaison Psychiatric Services within Fairfield Hospital contrary to NICE guidance. Therefore, the Coroner issued a PFD report.

Read the full case summary here.

Charlie Millers

Charlie Millers was a 17-year-old transgender boy who died following a ligature incident whilst a mental health patient on the Junction 17 ward, Prestwich Hospital in December 2020.

The inquest found multi agency failings led to Charlie’s death with Charlie ultimately not intending to end their own life. The jury also found that:

  1. Trafford Children’s Services did not engage with the mental health services and failed to provide support for Charlie’s mum and siblings. This resulted in Charlie being readmitted to Junction 17.

  2. Charlie should have been subject to a Child Protection plan.

  3. Charlie should have had an assessment in addition to his CAMHS plan to consider what he needed from a care perspective, to support him in the community.

  4. Record keeping on Pegasus ward was inconsistent and incomplete for the evening of 2 December.

  5. The decision not to place Charlie on 1:1 observations due to his decreased haemoglobin levels [following a previous self-harm incident] probably contributed to his death.

As a result of these findings, the coroner found it appropriate to issue a PDF report. Read the case summary here.

Awaab Ishak

Awaab Ishak was a two-year-old who sadly passed away on 21 December 2020. He lived with his parents in a housing estate in Rochdale, managed by Rochdale Boroughwide Housing (RBH).  Awaab’s parents had previously made complaints about the black mould present in the kitchen and bathroom and had also made requests for re-housing.

Over the weeks prior to his death, Awaab developed flu-like symptoms and had difficulty breathing. On 19 December 2020, he was taken to Rochdale Urgent Care Centre due to his difficulty breathing and was then transferred to Royal Oldham Hospital, where he was given supporting treatment and then discharged.

Awaab continued with difficulties at home and his breathing became worse, so his parents requested a GP and gave him medication. As his presentation was worsening, he was taken to Rochdale Urgent Care Centre on 21 December 2020, where he was found to be in respiratory failure. He was transferred to Royal Oldham Hospital where upon arrival he was in cardiac arrest and sadly was pronounced dead on the same day.

The Coroner has found the cause of death was: 1a) Acute airway Oedema with severe granulomatous tracheobronchitis 1b) Environmental Mould Exposure.

Northern Care Alliance NHS Foundation Trust (NCA) and RBH both made several admissions of failures at the inquest.

The Coroner has since issued a Prevention of Future Deaths report to the Minister for Housing and the Secretary of State for Health highlighting the concerns raised by this death. In addition she will be writing a letter to Rochdale Council and the NCA regarding the sharing of information between agencies and health related issues for the environment.

Read the case summary here.

Melanie Hart

Melanie Hart sadly died of multiple injuries including a severe head injury on 14th June 2023, having deliberately positioned herself in front of a train on the West Coast Mainline.

The Coroner raised concerns with a number of the interested persons describing their lack of responsibility towards the care of Melanie as a ‘Mexican stand-off’ situation, where no agency took adequate control to ensure Melanie’s safety.

Failings were found by Royal Edward Infirmary in respect of Melanie’s mental health care provision. Additionally, having heard numerous inquests involving issues with the standard of care at the Royal Edward Infirmary, the Coroner was frustrated that there can be as many as 4/5 patients awaiting inpatient mental health treatment, emphasising that this situation occurs far too frequently, citing issues with staff retention, recruitment, training, shift management and the need for dedicated resources as recurring themes that need to be addressed. The Coroner even committed to personally visiting the ‘Makerfield Suite’, the dedicated space for patients experiencing a mental health crisis who present at the Emergency Department to see the changes firsthand.

Regarding the role of Greater Manchester Police, DCI Jane Curran, the strategic lead for mental health stated that police have been criticised often by mental health trusts for overusing s136 powers. This was deeply concerning because it risks leaving individuals like Melanie, who are in crisis, without the necessary support and intervention at a time when they are most vulnerable.

Read the full case summary here.

Rowan Thompson

Rowan Thompson was an inpatient at the Gardener Unit, a medium secure adolescent mental health unit in Prestwich run by Greater Manchester Mental Health NHS Foundation Trust (GMMH). Rowan was 18 at the time of their death.

The jury found that Rowan died of Cardiac Arrythmia due to Severe Hypokalaemia of unknown cause, contributed to by neglect due to the failure to communicate the findings of blood tests. GMMH admitted several failings prior to the inquest, including in observations of Rowan. In addition, a number of failings were also admitted by Northern Care Alliance.

Following the jury’s findings, the Senior Coroner confirmed that she would be raising three issues in a Prevention of Future Deaths report, 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.

Read the case summary here.


GL died from drowning in the Gorton Lower Resevoir. His body was discovered on 26 November 2020 having been last seen on 10 November 2020. There was insufficient evidence to determine how he came to enter the water with the Coroner concluding his cause of death to be open.

Prior to his death GL had a long history of mental health illness and substance abuse. Between 4th June 20 and 15th June 20 he was detained pursuant to the provisions of the Mental Health Act 1983 at Eagleton Ward. Meadowbrook Unit.

GL’s discharge from Eagleton Ward was authorised via his mother using her nearest relative powers pursuant to the provisions of the Mental health Act 1983. GL then returned home.

According to evidence heard at inquest, GL was still liable to be held under s3 of the Mental health Act 1983; however, due to the difference in the test being applied for consideration of an application by a Nearest Relative, there was no choice but to discharge GL.

There was no consideration for a Community Treatment Order for GL. GL remained unwell in the community, and on 10th November 2020 he went missing before his body was found on 26th November 2020.

The Coroner issued a PFD report with the reply received from Maria Caulfield, politician serving as Parliamentary Under-Secretary of State for Mental Health and Women’s Health Strategy on 13th May 2024. The reply was extremely disappointing ignoring the concerns raised by the Coroner.


AB was 16 years old and was known to social services in 2005 due to concerns regarding exposure to drug use and physical abuse.

AB was subject to a Child Protection Plan and ultimately placed into foster care in 2006 due to concerns about neglect and the misuse of drugs at home. AB remained looked after until 2007 when AB returned to their father’s care. Social care became involved again when AB was around 10 or 11 years old. In January 2018 AB’s family confirmed they were no longer able to manage AB at home and keep the rest of the family safe, AB was therefore to move into a residential placement where they remained until their death in 2021.

AB was involved with multiple agencies throughout life and was a child with complex needs. AB had multiple vulnerabilities including early neglect, a difficult childhood, the fact AB was a looked after child, a history of exposure to Child Sexual Exploitation, mental health difficulties and a diagnosis of Autism Spectrum Disorder, along with some potential difficulties around eating and exploration of their gender identity. AB was first referred to Child and Adolescent Mental Health Services (“CAMHS”) in around 2009 or 2010 at the age of 5 or 6.

AB had a long history of self-harming, this started at 9 years old and was a theme throughout AB’s short life. AB experienced both auditory and visual hallucinations. AB would hear a male voice which told them they were worthless, would belittle AB, and encouraged self-harming. AB was found hanging at the residential care home (which was run by United Children’s Services) where they lived on 7 August 2021.

The Coroner noted concerns in relation to risk assessments, documentation and communication, walking night cover, compliance with care and support plans and United Children’s Services investigation policy and process requiring action. They are to respond to the report by 16th June 2024.


MB was a prisoner detained at HMP Garth who died of multi-organ failure amidst serotonin syndrome and drug toxicity, which included amitriptyline toxicity.

On the morning of 15th August 2022 MB was discovered unconscious in his cell by a prison officer, prompting a code blue response. An ambulance was called and then stood down. Throughout the next 14 hours MB remained largely unresponsive, disoriented and incoherent, with staff observing MB initially on frequent and then infrequent observations.

The jury deemed his death an accident, citing failure to consult Toxbase and ascertain MB’s prescription of amitriptyline as contributing factors.

The Coroner issued a report to prevent future deaths due to concerns that there is a risk that future deaths may occur unless action is taken. HMP Garth have a duty to respond to the report by the 22nd June 2024.

The Coroner specifically identified concerns in relation to;

  1. Existing welfare sheets lacking clarity regarding its exact purpose in terms of monitoring a prisoner whose health is of concern.

  2. The sheet contains little guidance in relation to its completion.

  3. Entries on the sheet made by prison staff appear not to have been made known to attending medical staff.

  4. The nature and operation of the sheet appears not to have been the subject of joint consideration on behalf of both prison and healthcare.

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