At some point in their career, many doctors will be required to attend an inquest to assist the coroner with an inquiry into the death of one of a patient.

If the coroner is concerned that further avoidable deaths could occur - for example, where several deaths have occurred at a known accident spot, or in the absence of a written policy at a prison concerning a suspected drug swallow - they have a duty to make a report to those they consider able to act. These are known as prevention of future deaths (PFDs) or Regulation 28 reports.

The coroner will usually announce their intention to make a PFD report in court at the end of the inquest. The PFD report should be sent by the coroner within 10 working days of the inquest and must be copied to the chief coroner and any 'interested person' (for example, the deceased's family) the coroner considers should receive it.

What to do if you receive a PFD report

In 2024, there were 713 PFD reports issued by coroners, up 25% compared with 2023. This represents 2% of all inquests concluded in 2024.

If you receive a PFD report, you need to submit a written response within 56 days of the date it was sent.

As per regulation 29(3) of The Coroners (Investigations) Regulations 2013, the response needs to set out:

• "(a) details of any action that has been taken or which it is proposed will be taken by the person giving the response or any other person whether in response to the report or otherwise and set out a timetable of the action taken or proposed to be taken; or
• (b) an explanation as to why no action is proposed."

In short, you need to demonstrate that you have reflected on the death, learned lessons, and taken action to prevent a similar incident from occurring.

There is no better way of demonstrating reflection than by undertaking a significant event analysis and preparing a summary report detailing:

• what happened
• why it happened
• what has been learned
• what has changed.

Demonstrating change

Here are some examples of points you might make to demonstrate that no change is required - or that a change is required and you have made it.

• No change: your secretary was on annual leave, and you were exceptionally short-staffed that particular week, which meant there was a delay in referring a patient to the mental health team, and the patient ended their life in the meantime. You perform an audit which shows this was a one-off incident; there has been no other delay in referring patients to the mental health team before or since the death in question.
• Change - example 1: you determined that a patient required an ECG and advised him to book an appointment with reception, not realising there was a four-week waiting list. The patient suffered a cardiac arrest and died while awaiting the appointment. You purchase an additional ECG machine in order to reduce the waiting list.
• Change - example 2: a patient died due to a pulmonary embolism. The clinician they consulted attributed their symptoms to asthma. The coroner found that their symptoms warranted referral to hospital. You ensure that all clinical staff are booked to attend a CPD course on the diagnosis of pulmonary embolism.
• Change - example 3: a patient being prescribed a medication known to cause cardiac complications died due to a cardiac-related condition. You introduce a new policy (or update an old policy), which states that all patients registered at the Practice who are being prescribed that particular medication must have an annual ECG.

Medical practitioners know better than anyone that prevention is better than cure. If you can take the steps described above before the inquest, you stand a good chance of persuading the coroner there is no need to issue a PFD report.

The importance of responding to a PFD report

The coroner has no power to take any action if they receive either no reply, or an inadequate reply. However, individual PFD reports and their responses are published on the Courts and Tribunals Judiciary website. Non-responses to PFD reports are also reported on this website.

The report for 2024 identifies 25 non-responses from a range of organisations including individual medical centres, royal colleges, NHS trusts, the Ministry of Justice and prisons, and it is possible to cross refer those non-responses with the PFD report issued and identify the particular concerns against the organisations.

As well as there being a reputational risk to your practice or organisation, the GMC's guidance in 'Good medical practice' (2024) is clear that to maintain patient safety, a registrant must co-operate with formal inquiries. This would arguably include responding to a PFD report.

How we can help

If you are asked to attend an inquest, either as a witness or an interested person, please contact the MDU as soon as possible. Our advice is likely to include considering whether a PFD can be avoided in your particular case, and/or responding to any PFD in the future.