Reports on Action to Prevent Future Deaths, otherwise known as PFD reports or Regulation 28 reports, are an important tool used by coroners in order to encourage organisations to make changes which may prevent future deaths.

These reports should be used to improve public health, welfare and safety. They should not be general in their content and they should be clear, focused and meaningful. They should be designed in a way so that they have a practical effect.

A PFD report does not have to be restricted to matters that were causative of the death in question.

PFD reports engage no right or obligation on the part of the recipient, aside from an obligation to respond to the report in writing within 56 days. A recipient may respond by either agreeing or disagreeing with the matters set out in the report. The recipient can also opt to either object or accept the recommended actions set out in the report. They can also respond by alleviating the coroner’s concerns and assuring the coroner no further action is required.

Challenging a PFD by judicial review - R (Dr Siddiqi and Dr Paeprer-Rohricht) -v- Assistant Coroner for East London

In the matter of R (Dr Siddiqi and Dr Paeprer-Rohricht) -v- Assistant Coroner for East London. Admin Court CO/2892/2017 (28 September 2017), the claimants, partners in a GP practice, made an application for Judicial Review to challenge the assistant coroner’s decision to issue a PFD report following the death of one of their patients. Having heard the evidence at inquest the coroner identified inadequacies in respect of the system operated at the GP surgery for receiving and acting upon patient summaries. Whilst the issues with the system were not found to have caused the death of the patient, the coroner was concerned that the existing system might put lives at risk in the future.

The application was made because the claimants believed that the factual basis upon which the PFD report had been issued was incorrect. They argued that the failure to note and act upon the deceased’s hospital discharge was an error made by an individual Locum GP and was not in consequence of the surgery’s system.

The claimants asked the coroner to withdraw his PFD report in consequence of the factual error. Whilst the coroner accepted the claimants’ evidence that the error was not systematic, as initially suspected, because the inquest had come to an end there was nothing that could be done to negate the duty he had (under Regulation 28) to make the report at the time of the inquest.

The decision

The application was dismissed and it was held that a coroner has no power to withdraw a PFD report once it has been made. It was confirmed that the appropriate remedy for those taking issue with a PFD report, was to respond to the report in writing (as per part 7 (2) of schedule 5 CJA 2009).

Given the decision in this matter it is difficult to see how Judicial Review could ever be the appropriate avenue for challenging a PFD, particularly where there was some evidence available at the time of the inquest to support the coroner’s concerns regarding potential future deaths.

Practical advice for responding to a PFD report

  • Recipients must respond to the PFD report in writing and they have 56 days to do so
  • A PFD report is only a recommendation and the coroner cannot insist that any particular action is taken. Therefore, if a PFD report is made, the recipient of the report is in a position to consider and/or investigate the concerns raised and respond as they deem appropriate
  • If changes have already been put into place since then set out these in response to the report and say whether these changes negate the need for further action
  • If the recipient of a PFD report thinks that the coroner has got it wrong then they can advise the coroner of this. The response is an opportunity to provide the coroner with the full picture and ‘set the record straight’
  • The chief coroner is able to publish responses and if a recipient is concerned about wrongful implications in the PFD report they are able to use the response as an opportunity to provide a clear and detailed rebuttal to the report
  • In cases where it is accepted that action should be taken, the response is a good opportunity to satisfy the coroner and assure the public and the deceased’s family that affirmative action is being taken to address any issues.