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May 31, 2023

On 29 March 2023, the Office for National Statistics released an article on Prevention of Future Death Reports for suicide submitted by coroners in England and Wales: January 2021 to October 2022. The research aims to identify themes from concerns raised in the PFD reports that may inform future research or policies for suicide prevention, including a new Suicide Prevention Strategy.

The research is helpful as it will assist families in knowing what topics a coroner may make a PFD report about and assist an Interested Person in considering relevant concerns to cover in preparation. This Inquest Update is a summary of the article, but the full report can be found here:

What is a Prevention of Future Death Report?

Coroners can issue a Prevention of Future Death (PFD) report to individuals or organisations where they feel action should be taken to prevent future deaths. The coroner’s role is to identify areas of concern rather than specific solutions.

PFD reports are sent to various organisations, including the NHS, government departments, professional bodies, and public services. The report is also sent to the deceased’s family, the Chief Coroner, and is available on the Courts and Tribunals Judiciary website.

What concerns were raised?

There are around 5,000 suicides registered in England and Wales each year, and there were 164 PFD reports in 2021 and 2022 (96 reports from 2021 and 68 reports from 2022). It follows, therefore, that PFD reports are only issued for a small number of cases.

Coroners’ concerns, also referred to as “concerns”, are points highlighted on the PFD reports where the coroner believes action should or could have been taken to prevent death. In 164 PFD reports, a total of 485 concerns were identified, with an average of three concerns per report.

The data shows 12 core concerns and several sub-themes. The core and subsidiary concerns are set out below in order of how many times each sub-theme was mentioned:

  1. Processes – 142 concerns from 89 PFD reports
    • Inadequate monitoring and documenting of processes
    • No processes in place
    • Inadequate safeguarding or care processes
    • Processes not followed due to inadequate staffing
    • Delays in commencing or escalating processes
    • Processes not clear
    • Other
    • Engagement and information relay to deceased
    • Inadequate review or investigation after incident
    • Processes impacted by limitation in technology used
    • Inadequate observation processes
    • Processes lack independence or risks to disclosing
    • Information
  2. Access to Services – 84 concerns in 52 PFD reports
    • Delays in accessing services
    • Inadequate staffing
    • Service not appropriate
    • Delays with referrals
    • No service available
    • Access impacted by COVID-19
    • Disengagement from deceased
    • Multiple services involved impacting access
    • Requests not fulfilled
    • Out of area
  3. Assessment and Clinical Judgement – 78 concerns in 55 PFD reports
    • Risk not correctly assessed
    • No risk assessment undertaken
    • Risk assessment not suitable
    • Processes in assessment
    • Staffing issues involved in assessment
    • Error in assessment
    • Risk not updated
    • Diagnosis
    • Assessment impacted by COVID-19
  4. Policy – 77 concerns in 45 PFD reports
    • No policy in place (processes)
    • Inadequate policy
    • Knowledge gaps in existing policy
    • Policy not used in practice
    • Review required (incidents and safeguarding)
    • Other
    • No policy in place (sharing information)
    • No records of compliance to policy
    • Proposal policy made but not implemented
  5. Communication – 68 concerns in 55 PFD reports
    • Inadequate communication between services
    • Family not involved in care
    • Medical notes not updated or inadequate
    • Inadequate communication with deceased
    • Inadequate communication between staff (within service)
    • Inadequate communication with professionals closest to deceased
    • Information on risk not communicated to service
  6. Products – 41 concerns in 25 PFD reports
    • Access to medical products (e.g. medication)
    • Other
    • Access to harmful internet and social media content
    • Access to area (e.g. railway)
    • No access to products to save life
    • Access to substances (e.g. drugs)
  7. Training – 50 concerns in 30 PFD reports
    • Current training not adequate
    • Issues with access to training
    • Other
    • Training following incident required
  8. Culture – 28 concerns in 25 PFD reports
    • Inadequate staffing and/or way of working
    • Bullying
    • Diagnosing
    • Dismissive culture
    • Incorrect assumptions made
    • Therapeutic environment or relationships
  9. Improvements Not Being Implemented – 25 concerns in 20 PFD reports
    • Information, guidance, and training for staff
    • Access or CCTV at high-risk areas (community)
    • Delays in improvements
    • Hospital room adaptations
    • Medical equipment or clothing
  10. Care Plan – 29 concerns in 25 PFD reports
    • Issues with care plan process
    • Care plan not suitable
    • No care plan in place
    • Issues with care plan for carers
  11. Room, Cell, or Ward Physical Environment
  12. General Risk Factor
    • NB: “General risk factor” includes broad larger scale societal factors that could lead to future deaths. Number of mentions is not presented on the figure as counts were low and could result in statistical disclosure.

The further 83 subsets which can be found here:

From the data identified from the ONS, it is clear that the majority of concerns fell in the ‘processes’ category. The next three categories are ‘access to services’, ‘assessment and clinical judgement’, and ‘policy’.

In respect of processes, 54% of all reports related to “processes”, with “inadequate monitoring and documenting of processes” being the most common sub-theme. This sub-theme related to processes not being recorded or standard operating procedures not being followed, thus potentially contributing to a death. For concerns under the second most common sub-theme, “no processes in place”, evidence demonstrated that there were no processes or standard operating procedures, and if they had been in place, a death may have been prevented.

How can I use this?

For those representing Interested Persons who may be at risk of being the recipient of a PFD report, the analysis assists with pre-inquest preparation in highlighting some of the major areas that coroners tend to focus on when considering whether a PFD report should be made. It answers the question that many of our clients ask, namely ‘what sort of things might a coroner make a PFD report about?’

For those representing the family of the deceased, or any other Interested Person who might encourage the coroner to make a PFD report, the analysis provides several suggestions as to how a family’s concern(s) might translate into the sort of concern a coroner would include in a PFD report. As is often the way in inquest advocacy, framing a submission in a way that means the coroner can immediately adopt the suggestion is likely to increase its chances of success.

Simran Kamal
May 2023