When an inquest looks beyond one death

Prevention of Future Deaths Reports: what families and businesses need to know

A practical guide to Regulation 28 reports in coroners’ inquests in England and Wales

When an inquest looks beyond one death

An inquest is primarily concerned with answering four questions: who died, and when, where and how they came by their death. In many cases that is where the formal process ends. Sometimes, however, the evidence heard by the coroner points to a wider risk. It may be a gap in a system, a poor practice, an unsafe process, or a hazard that has not been properly addressed.

That is where a Prevention of Future Deaths report can become important. It is not a claim for compensation. It is not a finding of civil or criminal liability. It is a formal warning from the coroner that, unless action is taken, there is a risk that someone else may die in similar circumstances.

What is contained in a Prevention of Future Deaths report?

A Prevention of Future Deaths report, often called a PFD report or a Regulation 28 report, is a written report made by a coroner under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009 and regulation 28 of the Coroners (Investigations) Regulations 2013.

A report will be produced if an investigation reveals circumstances creating a risk of other deaths, and the coroner is of the opinion that action should be taken to prevent those circumstances continuing or recurring. The report is sent to the person or organisation that may have the power to take that action.

The language is deliberately forward-looking. A PFD report is about prevention, not punishment. It should be clear, focused and practical. The coroner is not there to run a public inquiry into every possible issue, but where a real ongoing risk is revealed, the law requires the coroner to act.

At what stage is one issued?

A PFD report may be issued during the course of the coroner’s investigation, but it will usually be considered at or after the conclusion of the inquest, once the coroner has heard the relevant evidence. Regulation 28 provides that the report may not be made until the coroner has considered the documents, evidence and information that the coroner considers relevant to the investigation.

Families, businesses and other interested persons can draw the coroner’s attention to concerns that may justify a report. They cannot compel the coroner to issue one. That decision rests with the coroner. In practice, well-prepared submissions made at the right time can help identify whether the evidence has revealed an ongoing risk and who is best placed to address it.

Who writes it?

The report is written solely by the coroner who is investigating the death. It does not contain contributions from the family of the deceased, the police, a regulator or any other interested person.

That does not mean others have no role. Inquest evidence is often provided by witnesses, experts and organisations involved in the events leading to the death. Interested persons may also make submissions. The coroner then decides whether the statutory test is met for a report being required and, if so, who should receive it.

Who has to implement the report?

The report is addressed to the person, organisation, local authority, government department or agency that the coroner believes may have the power to take action. That might be a hospital trust, a care home operator, a local authority, a government department, a product manufacturer, a transport operator, a school, a regulator, an employer or a private business.

The recipient must respond in writing, usually within 56 days. The response should explain what action has been taken, what action is proposed, and the timetable for that action. If no action is proposed, the response should explain why.

A PFD report does not usually prescribe the exact solution. It identifies the coroner’s concern. The recipient is expected to consider that concern seriously and decide what measures are appropriate. In that sense, the legal obligation is to respond, but the practical and reputational pressure to act can be significant.

Why it matters to families

For a family, a PFD report may provide something that the inquest conclusion alone cannot. It can show that the death has led to a formal warning and that a public body, company or organisation has been required to explain what it will do differently.

This can be an important part of the family’s search for answers. It may also help them feel that lessons are being learned. That does not remove the grief or necessarily provide accountability in the way a family might hope, but it can make future safety the focus of the final stage of the inquest process.

There are limits. A PFD report is not compensation. It is not a declaration that an organisation was negligent. It will not, by itself, establish legal liability. Families considering a civil claim, complaint or regulatory referral should take advice on those routes separately.

Why it matters to businesses

For a business on whose premises a death occurred, a PFD report can be serious. It may identify concerns about systems of work, risk assessments, supervision, maintenance, training, access arrangements, signage, emergency response procedures or the physical condition of the premises.

The report and the response are generally sent to the Chief Coroner and may be published. That means the issue can become visible to regulators, insurers, customers, employees, journalists and competitors. Even where there is no finding of liability, the public nature of the process can have real commercial and reputational consequences.

A business receiving a PFD report should deal with it promptly and carefully. The response should be accurate, evidenced and realistic. Over-promising can create problems later. Under-responding may suggest that the risk has not been understood. In many cases, the sensible approach is to review relevant policies, preserve documents, notify insurers where appropriate, and take specialist legal advice before the response is finalised.

Careful preparation before the inquest

Whoever is acting for a bereaved family or for an organisation involved in the circumstances of the death, preparation matters. The possibility of a PFD report should be considered early, not as an afterthought once the inquest has finished.

For families, that may mean identifying unanswered questions and any ongoing risks. For businesses, it may mean showing what has already changed, why those steps are sufficient, and how future risks are being managed. A clear, measured approach can help the coroner, assist the family and reduce the likelihood of avoidable misunderstandings.

The key point

A Prevention of Future Deaths report is one of the most practical outcomes an inquest can produce. It does not decide who is to blame. It asks what needs to change so that another death is less likely.

For a family, it may be a route to wider learning. For a business, it may be a prompt for urgent review and careful public response. For both, it is a reminder that the inquest process is not only about the past. Sometimes it is also about preventing what might otherwise happen next.

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This article aims to supply general information, but it is not intended to constitute advice. Every effort is made to ensure that the law referred to is correct at the date of publication and to avoid any statement which may mislead. However, no duty of care is assumed to any person and no liability is accepted for any omission or inaccuracy. Always seek advice specific to your own circumstances. Fraser Dawbarns LLP is always happy to provide such advice.