Prevention of Future Death reports - An update

Last year, we reflected on [1] the Chief Coroner’s decision to ‘name and shame’ those who had failed to respond to Prevention of Future Death reports (PFD). Over 12 months on, we reflect on what has changed, and if the approach has been a success.

Background

In 2025, for the first time the Chief Coroner, Her Honour Judge Alexia Durran, published the names of organisations, including public and corporate bodies, who had failed to respond to a PFD report. The list is published on the Judiciary website and is updated every six months [2].

A coroner has a duty to report any concerns of circumstances that create a risk of future deaths to anyone identified as having the power to take action to prevent, eliminate or reduce the risk of death created in such circumstances [3].

Unless an extension is agreed by the coroner, the recipient of a PFD report is obliged to provide a written response within 56 days of the date the report is sent [4]. The response should include what remedial action has been, or will be taken and when, or an explanation as to why no action is proposed [5].

Whilst this obligation is enshrined in law, there is no penalty or sanction for a failure to respond. As such, the Chief Coroner, hoped that the public ‘‘badge of dishonour’’ of non-respondents being publicly named online, would in and of itself prompt responses.

Developments

In the Chief Coroner’s latest annual report [6], she shares that, despite the fresh approach, there were still 16 reports issued in 2024 that have one or more responses outstanding. Our review of the Judiciary website suggests that two responses were two years overdue (and counting).

As discussed in our previous article, and in the Chief Coroner’s own words, ‘‘once a PFD report has been issued,’’ apart from allowing an extension ‘‘the coroner has no legal power to take any further steps’’.  This in her view is ‘‘as it should be’’ given ‘‘coroners are judges, not regulators.’’

As well as publishing an updated list of non-responders, on 1 January 2025, the Chief Coroner issued the ‘Bench Book’ [7]. It was hoped this document would provide practical assistance to coroners across the country, with the aim of increasing the consistency of service across England and Wales.

The Bench Book reinforces that even if no response is provided, the coroner, in issuing a PFD report has ‘‘completed their function’’ and ‘‘no longer has a mandate to take any further steps’’ citing that chasing a missing reply would ‘‘exceed their powers.’’

The suggested approach is writing to inform the bereaved family, any other recipients of the original PFD report, as well as the non-respondent themselves to highlight the lack of acknowledgment on the basis that this may ‘‘generate a delayed response.’’

Similarly, where a response has been provided, but is deemed ‘‘inadequate’’ [8] the coroner could send the inadequate reply to another body who may find it ‘‘useful or of interest.’ ’[9] The Bench Book gives the example of contacting a national body or regulatory authority that oversees the non-respondent.

Comment

Although widely accepted, it is interesting that the Chief Coroner herself has directly acknowledged the lack of power a coroner has once a PFD has been distributed.

Rather than advocating for reform to provide such a power, the Chief Coroner explicitly advocates coroners staying within a strict remit, even if this means that the process ‘lacks teeth’.

Whilst the PFD function is ‘‘ancillary’’ [10] to the primary purpose of an inquest, it is difficult to reconcile the coroner’s duty to report such risks, the specific legal duty to respond to a PFD within 56 days and the open acknowledgment that if an organisation fails to respond, there will be no meaningful sanction from the coroner.

This offers the potential for a two-tier system with responsible organisations that are conscious of their public reputations and relationships with regulators taking the proper step of responding, and others that do not failing to do so without reproach.

Instead of proposing reforms to introduce meaningful enforcement powers, the Chief Coroner appears to be advocating for reliance on non‑respondents’ ethical convictions by highlighting this lack of engagement to bereaved families, naming them online and potentially drawing it to the attention of regulators or senior figures within the relevant sector.

Clearly the inquest process itself is likely to be upsetting and arduous for a bereaved family. However, it is hoped that it should answer some of their questions and provide a sense of closure. On that basis, it could be argued that involving the family post inquest, to elicit a response from the recipient of a PFD, may actually be counterproductive and risks reliving past distress.

Taking a more holistic view of the current approach, in 2024, 713 PFD reports were published across 39,000 inquests concluded that year. In her latest report, the Chief Coroner stated that only 16 PFDs issued had not been responded to during the same period. This means around 2% of inquests led to a PFD and of those issued with a PFD just over 2% failed to respond.

The statistics suggest that, while there are instances of non‑compliance with the legal obligation to respond to PFDs, these cases appear to sit at the margins of an otherwise broadly effective system. On that basis, substantial reform may not be warranted.

Alongside that and whilst not directly acknowledged by the Chief Coroner there must also be a reluctance to impose an additional enforcement function on an already stretched and under‑resourced public body.

Whatever comes next, it seems unlikely that substantive reform to the system will follow and the Chief Coroner will instead effectively focus on creating a sense of obligation for organisations who wish to avoid reputational damage to elicit responses to those who fail to respond to PFDs of their own volition. In doing so, she may inadvertently allow those who are not conscientious to continue to flout the rules.