Prevention of Future Death reports (PFDs) are very much a live issue in the minds of most trusts. A coroner not only has a power, but is under a duty to make reports to a person, organisation, local authority or government department or agency pursuant to paragraph 7 of Schedule 5, Coroners and Justice Act 2009.
What to think about before an inquest
When preparing cases for inquest, it is always wise to have the possibility of a PFD at the back of your mind.
Where there has been a root cause analysis or serious incident investigation, you should consider the learning arising from that investigation and where possible ensure that any action plan is completed and evidenced fully. The coroner may also wish to hear live evidence from someone who was involved in the preparation of that report.
Also, do consider if there are any other areas for learning above and beyond what has been covered in the investigation report.
Where there hasn’t been such an investigation, consider what learning might arise in any event – even where no harm has occurred. Think about personal reflection for clinicians and presenting case studies at a clinical governance meeting as ways to show your organisation’s commitment to learning. Even if no incident was declared at the time, be live to the issues which arise during the preparation for an inquest and consider declaring an incident investigation retrospectively if the circumstances suggest it.
When you have received a PFD
Despite the above, there may still be occasions when a report is issued.
Healthcare organisations are sometimes concerned that the PFD has been incorrectly issued or is based on a factual error.
In those circumstances, the recent case of R (Dr Siddiqi and Dr Paeprer- Rohricht) -v- Assistant Coroner for East London highlighted that the proper reaction is not usually to bring judicial review proceedings. A coroner has no power to withdraw a PFD report once it has been made. Instead, organisations should respond in writing to the coroner who has issued the PFD in all circumstances (pursuant to paragraph 7(2) Schedule 5 Coroners and Justice Act 2009), even if you disagree with part or all of the PFD.
In formulating such a response an organisation should consider:
- Any changes that have already been made.
- Any scope for further changes to be made. If you consider that no such changes are required, say so, but set out why not ie. because the changes you have already made are sufficient to prevent future deaths occurring.
- Any facts in the PFD that have been set out in error such as the area for concern being the responsibility of another body. If you think that the coroner has got it wrong, explain why, setting out as much detail as possible.
- If you accept that action is required, set out what steps the trust has/is taking to address the issues. Include details such as dates of meetings, results of audits or content of circulations. Where possible exhibit any evidence to your response.
Organisations have 56 days in which to respond to the PFD.
PFDs are published centrally, but it is important to note that the chief coroner is also able to publish responses to PFDs. This should be of some comfort to those who feel that a PFD was wrongfully issued – the focus should be on providing as full a rebuttal as is possible.
We are able to assist with the assessment of risk of a PFD prior to an inquest, as well as taking steps to reduce the chance of one being issued. We are also able to assist in the formulation of responses to PFDs.