Prevention without power: Rethinking the UK's Coronial PFD system

One of the most compelling aspects of the coronial jurisdiction in England and Wales is its potential to prevent future deaths by identifying systemic risk factors associated with individual cases. Central to this function is the Prevention of Future Death (PFD) report mechanism, which is intended to prompt those best placed to implement necessary measures. This system has been increasingly criticised as being unfit for purpose due to factors such as limited coronial powers and a lack of national oversight.

This article advocates for a re-evaluation or reconsideration of the PFD framework. It explores international models, particularly from Australia and New Zealand, which have successfully nationalised risk identification through unified databases. These models offer valuable insights for the United Kingdom in improving the efficacy and reach of coronial recommendations.

PFD Reports: Legal Basis and Current Practice

Under the Coroners and Justice Act 2009 and associated regulations, if a coroner identifies concerns that pose a risk of future deaths during an investigation, they are obligated to issue a PFD report to the person or organisation best placed to take remedial action[1].

The statutory threshold for issuing a PFD report is relatively low: it need not relate to the cause of death but may address any matter arising from the investigation that raises concern of a risk of future deaths [2]. However, this is assessed in light of practices current at the time of the inquest. In practice, coroners often exercise discretion not to issue a report where effective remedial action has already been taken, arguably raising the threshold beyond that envisaged by statute. This position is reinforced by case law, which affirms the primacy of coronial discretional over prescriptive criteria.[3]

Recipients of PFD reports are legally obliged to respond within 56 days, although extensions may be granted. [4] These responses must outline the action taken or planned in light of the report or explain why no action will be taken. [5]

Limitations of PFD Reports

The principal aim of a PFD report is to mitigate ongoing risks to life. However, the preventative potential of PFD reports has faced substantial criticism for its limited practical effectiveness.

a) Lack of enforcement powers

 Although recipients are under a legal obligation to respond to a PFD report, there are no statutory sanctions for non-compliance. Coroners lack enforcement powers; they cannot compel organisations to respond, nor can they intervene if a response is inadequate or absent. Further, even in circumstances where the recipient does provide a response, but it indicates that they have already made relevant changes, coroners lack the power to test any such claims. Once the inquest concludes, the coroner’s formal involvement ends, eliminating any avenue for follow-up or sustained oversight.

It is therefore unsurprising that historical compliance with PFD reports has been inconsistent. Data from the PFD Tracker [6], indicates that as at 1 July 2025, 25.2% of PFD report responses were overdue. [7]

b) Quality of PFD Reports: Limitations in Research Capacity, Accessibility and Scope

 The effectiveness of a PFD report relies significantly on the coroner’s ability to draw on insights from previous reports to identify recurring themes and systemic risks. However, this integration currently depends on an individual coroner’s capacity to undertake independent research or on prior personal familiarity with relevant cases. In practice, this means that valuable learning opportunities, especially opportunities for national-level learning and reform, are often missed.

Coroners have voiced concerns over the limited accessibility and functionality of the existing PFD report database.[8] While the online repository on the Judiciary website has seen some recent improvements, it still lacks comprehensive thematic tagging and advanced search capabilities. As a result, coroners working under tight time constraints may find it impractical to locate and analyse relevant past reports. These inefficiencies are hindering the development of well-informed, thematically robust PFD reports. This highlights the need for a centralised and adequately resourced repository to support coroners in accessing and then applying insights from prior reports, an issue explored further below.

In addition to these practical limitations, the statutory scope of PFD reports is also inherently constrained. Coroners are limited to identifying risks and areas of concern in their reports; they are explicitly prohibited from making prescriptive recommendations or specifying remedial actions.[9] This contrasts with jurisdictions such as Australia and New Zealand, where coroners are empowered to issue formal recommendations aimed at preventing similar deaths and enhancing public safety. These broader powers arguably enable a more proactive and impactful approach to death prevention.

Although it might be argued that individual organisations are best placed to determine and implement suitable responses, the UK model frequently leads to inaction, particularly when responses face political, operational or budgetary obstacles. A review by the Independent Advisory Panel on Deaths in Custody (IAPDC), which sampled responses to PFD reports, found that very few responses included specific timelines for implementation, and almost no responses referenced wider systemic implications or relevant national evidence.[10] This lack of accountability and strategic follow-through underscores the limitations of the current framework and reinforces a case for reform.

c) Localised Impact and the Need for National Learning

 The limitations of PFD reports extend beyond their scope and quality to include issues around dissemination and national impact. As noted in the IAPDC review, there is currently a significant “distribution issue”, whereby coroners are failing to share their reports beyond the immediate parties involved to, for example, relevant oversight bodies, national agencies, or stakeholders.[11] This lack of wider circulation restricts the opportunity for shared learning and coordinated reform.

As a result, even when action is taken in response to a PFD report, it frequently occurs in isolation and at a local level. A hospital, for instance, may implement changes to address the specific failings identified in a report, but unless the findings are escalated and generalised, similar risks may remain unaddressed in other institutions.

Without a formal structure to facilitate the national collation, analysis, and dissemination of the concerns raised in PFD reports, the regime risks repeating the same lessons in silos. A mechanism for national learning is therefore essential, not only to ensure that serious risks are addressed consistently across regions and sectors, but also to enable the translation of local incidents into broader policy reforms.

These shortcomings collectively cast doubt on whether the PFD system is achieving its statutory objective: to prevent future deaths in similar circumstances. Instead, the current regime is overly reliant on voluntary compliance, reputational pressure, and goodwill. In the absence of enforcement capabilities or systemic reform, the PFD system risks becoming a procedural formality rather than a meaningful instrument of death prevention.

Recent Developments in England and Wales

On 9 September 2024, the Chief Coroner for England and Wales, Her Honour Judge Alexia Durran, announced a new policy aimed at increasing accountability for organisations that fail to respond to PFD reports. Effective from 1 January 2025, this policy introduces a publicly available "non-response list" on the Judiciary website. This measure effectively imposes a reputational penalty on non-compliant bodies.

While this development is incredibly helpful and will improve response rates, it does not resolve the more fundamental question of whether the current PFD framework is operating effectively to prevent future deaths or drive systemic reform. Enhancing visibility of non-compliance is a step forward, but without a mechanism to address the systemic issues, the underlying limitations of the regime remain.

Further scrutiny is currently being undertaken through the ongoing Lampard Inquiry into mental health inpatient deaths in Essex. The Inquiry is closely examining the role and effectiveness of PFD reports within the broader coronial and regulatory landscape. Specifically, it is investigating how PFD reports are issued, the quality and consistency of their content, and the degree to which they prompt effective action, not only from NHS trusts and individual clinicians, but also from national regulatory bodies. A central concern for the Inquiry is whether a systemic oversight gap exists, particularly in relation to post-inquest accountability and the follow-through of any responsive actions, and whether any additional mechanisms are needed to support continuous learning and risk reduction in high-risk settings.

The outcome of the Inquiry may play a pivotal role in determining whether the current PFD regime evolved into a more accountable and nationally coordinated system.

Recommendations for Reform

1. Creation of an Independent Oversight Mechanism

The establishment of an independent statutory body could be a key reform, tasked with overseeing responses to PFD reports. This body would monitor any actions taken by organisations in response to coronial findings. It should also be empowered to compel responses and scrutinise whether actions are adequately addressing the risks identified in the PFD reports.

This body should also assume the public reporting function currently held by the Chief Coroner, alleviating pressure from their office. By taking on this responsibility, the independent oversight body could publish compliance data which, in turn, would provide for consistent accountability.

2. Fostering Cultural Change

Organisations must be encouraged to view PFD reports as opportunities for learning and improvement, rather than as criticisms. To facilitate this shift, training initiatives could be implemented for key personnel, including coroners, healthcare professionals, and organisational leaders. These training programs should emphasise the value of PFD reports, their role in risk management, and their potential to drive meaningful change. In turn, this would help facilitate a culture of continuous improvement and enhance the quality and timeliness of responses.

3. Establishment of a National Research Function

The UK Government could fund and establish an independent national research function dedicated to collecting, analysing and disseminating data which underpin PFD reports and identifying trends and patterns across sectors. Helpfully, this function would assist coroners when drafting PFD reports by providing critical data and evidence to guide the contents of the reports. In turn, this would improve the quality of PFD reports and facilitate a more consistent approach to prevention.

The existing PFD Tracker, founded by Dr Georgina Richards, has already demonstrated the value of such an approach. Although it currently operates without government funding, it has proven to be effective in identifying patterns and trends across PFD reports. Providing government funding to support this tracker, or establishing a similar national research function, would significantly enhance national coordination and improve the overall efficacy of the PFD regime.

4. Consideration of a Nationalised Model

Alternatively, the UK may wish to consider changing the current PFD system altogether in favour of a nationalised, data-driven approach to managing coronial findings. In practice, this model would adopt the functions of both the independent oversight body and national research function discussed above, to provide a more coordinated response to systemic risks.

A nationalised model would streamline the current process. By consolidating and centralising relevant data regarding recurring risks, it would see a shift from individual, localised PFD reports to more evidence-based, national-level recommendations, policy reforms and interventions. This would ultimately reduce the need for separate reports.

Countries such as Australia and New Zealand have successfully implemented similar systems. The National Coronial Information System (NCIS) was established in 2020 and serves as a centralised data repository for all reportable deaths across Australia and New Zealand. The NCIS offers a free research service to coroners, facilitating the production of tailored recommendations based on national mortality trends. The system is also used by policymakers, researchers, regulatory bodies, and safety advocates to inform legislative and operational reforms. A notable example is the NCIS’s role in addressing quad bike fatalities. Data collected by the NCIS contributed to the implementation of multiple safety initiatives, including mandatory helmet use and roll-over protection subsidies.[12]  Similar data-driven interventions have targeted infant strangulation from blind cords, unintentional fires, and vehicle-related accidents.

Conclusion

This article has examined key challenges of the current PFD framework, particularly in relation to enforcement, research capability, and national coordination. It has highlighted the advantages of international approaches, particularly those adopted in Australia and New Zealand, which demonstrate the practical benefits of national oversight, structured data analysis, and evidence-based policymaking in maximising the preventative potential of the coronial jurisdiction.

By looking outward and adopting selected elements of these models, the UK has an opportunity to enhance its own system: preserving coronial independence while improving national learning, response consistency, and long-term effectiveness. Reform need not imply rejection of the existing structure, but rather guide its evolution into a more coordinated, data-informed model of death prevention - one that is cohesive, proactive and grounded in evidence, accountability, and systemic learning.

Authors: Molly Windsor and Emily Pilborough

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[1] The Coroners (Investigations) Regulations 2013.
[2] Coroners and Justice Act 2009, Schedule 5, paragraph 7(1); Chief Coroner’s Guidance No.5 ‘Reports to Prevent Future Deaths’, paragraph 17.
[3] See R (Diarra Dillon) v HM Assistant Coroner for Rutland and Norther Leicestershire [2022] EWHC 3186 (KB).
[4] The Coroners (Investigations) Regulations 2013, Regulation 29(4) and (5).
[5] The Coroners (Investigations) Regulations 2013, Regulation 29(3).
[6] The PFD Tracker is a UK database which compiles and analyses coroner’s PFD reports to identify trends and lessons for improving public safety and preventing future deaths
[7] See https://preventabledeathstracker.net/database/.
[8] See “More than a paper exercise” – Enhancing the impact of Prevention of Future Death Reports, Independent Advisory Panel on Deaths in Custody, paragraph 58.
[9]Chief Coroner’s Guidance No.5 ‘Reports to Prevent Future Deaths’, paragraph 24.
[10]See “More than a paper exercise” – Enhancing the impact of Prevention of Future Death Reports, Independent Advisory Panel on Deaths in Custody, paragraph 91.
[11] See “More than a paper exercise” – Enhancing the impact of Prevention of Future Death Reports, Independent Advisory Panel on Deaths in Custody, paragraph 71 and 72.

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