Prevention of Future Deaths Reports – The ‘No More Deaths’ Campaign

Whilst the key focus of an inquest is usually the question of how a person came by their death, for many Interested Persons, including NHS trusts and other healthcare providers, the most important issue is whether the coroner will issue a Prevention of Future Deaths (PFD) report.

A coroner has a duty to take action to prevent future deaths where:

1. a coroner has been conducting an investigation into a person’s death;
2. anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist in the future; and
3. in the coroner’s opinion, action is required to prevent the continuation of such circumstances, or eliminate or reduce the risk of future death created by such circumstances.

The problem is that, following these PFD reports, the suggestions made are not being implemented as the coroner has no legal powers of enforcement.

Campaigners, including our client Richard Caseby, are pushing for change, calling the UK strategy for preventing repeat deaths ‘a systematic scandal’.

Richard sadly lost his son, Matthew Caseby, in 2020 and an Inquest found that there was a litany of failure and negligence by The Priory Hospital Woodbourne, who in just three days had been so negligent it was responsible for two fundamental causes of Matthew’s death and 29 contributory factors.

The coroner at Matthew’s inquest made clear recommendations in the PFD report about the height of fences in acute psychiatric units but to this day, Richard has no idea as to whether this has been implemented.

Richard is now working with the charity INQUEST on their ‘No More Deaths’ campaign, alongside other bereaved families to push for change to the system to ensure that when suggestions are made, that there is a legal responsibility to act on those suggestions to, quite literally, prevent future deaths.

INQUEST is the only charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Their specialist casework includes deaths in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question. This includes work around the Hillsborough football disaster and the Grenfell Tower fire.

INQUEST is calling for a National Oversight Mechanism to;

• Collate recommendations and public bodies’ responses in a new database
• Analyse responses from public bodies & issue reports
• Follow up on progress, escalate concerns & share thematic findings

Head of our Public Law and Private Litigation team, Craig Court, fully supports the ‘No More Deaths’ campaign: “it is horrifying that when a coroner has taken the time to fully investigate someone’s tragic death in order to make recommendations in a Prevention of Future Deaths report, that there is no culpability if these recommendations are not acted upon. I fully support Richard’s brave involvement with the INQUEST campaign to ensure that no family has to go through what he has and that his son’s death will not be in vain”.

How can we help?

Having legal representation before and at an inquest means there is a qualified legal professional who can give informed and objective advice to help guide you through the process and explain what is happening. At Harding Evans we have extensive experience in dealing with inquests and can provide you with the quality legal support you need.

If you need advice in this area, please contact us today.