NHS England outlines how it will respond to Prevent Future Deaths reports

New guidance on Action to Prevent Future Deaths Reports (PFD) (Regulation 28) sets out how to issue a PFD to NHS England (NHSE) and the processes it will follow, including how these reports support system wide patient safety learning.

The Chief Coroner’s annual report for 2023 indicates a rise in coroners’ PFD reports – 550 reports were issued in 2023, an increase of 132 compared to 2022. These reports highlight NHS pressures such as long waits, staff shortages or a lack of resources.

Following an inquest or investigation into a death, a coroner may issue a Regulation 28 PFD report to a person, organisation, local authority, government department, or agency where the coroner believes that action should be taken to address some of the identified concerns to prevent future deaths.

Recipients of the PFD report are legally required to respond within 56 days. While extensions can be requested from the coroner, they are not guaranteed. All reports and responses must be sent to the Chief Coroner and in most cases the Chief Coroner will publish them on the Courts and Tribunals Judiciary website.

At a glance

The guidance explains:

NHSE’s PFD processes

Reports are logged and coded for demographics, place of death and the main issue highlighted by the coroner. This approach allows NHSE to identify new and emerging themes that may require ‘further review or escalation’.

There are seven NHS regions and each has a designated PFD leads who will input into response and those leads may also engage with the wider system including with Integrated Care Boards.

Regulation 28 Working Group

This internal multi-professional group work alongside NHSE’s executive quality group to undertake a range of functions:

• meet to discuss all NHSE responses to PFDs and undertake due diligence
• share insights with systems/Integrated Care Boards
• track and monitor actions required, and commitments made within responses
• consider if additional actions need to be taken or escalations made
• undertake thematic reviews into emerging themes or issues
• publish an annual report each year analysing PFDs received and reviewing responses and themes

NHS structures and organisational mergers

Reference is made to the recent tranche of mergers between national and NHS organisation to create NHS England. The functions of NHS Improvement, NHS Digital, NHSX, Health Education England and some former functions of Public Health England.

PFDs that involve these functions should all now be sent to england.coroners28@nhs.net for the attention of the national medical director.

The guidance reminds coroners to consider the commissioning landscape and functions when sending PFDs to NHS organisations.

New Chief Coroner

As Her Honour Judge Alexia Durran takes the helm as the new Chief Coroner of England and Wales in succession to His Honour Judge Thomas Teague KC, we are likely to see some changes as outlined in the Coroner’s 2023 annual report.

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