Coroners Reports to Prevent Deaths

The following article, dated June 2020, focusses on the way in which coroners report on things that have gone wrong in care homes, when looking at causes of death.

We Advise and Represent care Homes and Care Establishments in Inquest Proceedings

The Coroners and Justice Act 2009 Sch 5 para 7(1) requires a coroner to make a Report to Prevent Future Deaths (PFD) where:

(a) …

(b) 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

(c) in the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances. 

The Report is directed to the person who the coroner believes may have the power to take such action. This could be more than one person on the same issue for example a Care Home and the CQC, CIW, Ofsted, the local CCG, the local authority.

A copy of the PFD report and responses are sent to the Chief Coroner and are published on the Courts Tribunals and Judiciary website. Care Homes are a specific sub-category. Such publications can therefore have an adverse effect on the reputation of a care home, and steps should ideally be taken in advance of an inquest, to seek to avoid there being a need for a coroner to publish a report. Our service can assist care home providers in seeking to evidence good practice and improvements, so reassuring a coroner that all has been done in the circumstances to prevent repetition or the risk of death.

Between 31 December 2019 and 22 April 2020 coroners across England and Wales have made 11 PFDs where care homes have been identified. Bearing in mind that the 2009 Act has been in force since July 2013, this is a rather high number. This may be because there is no statutory system for circulating PFDs and responses to all care homes, such that wider learning opportunities are missed.  Consequently, the reasons for a coroner making a PFD in one part of the country may be highlighting the theme of an earlier PFD elsewhere.

 An analysis of the PFDs between 31 December and February 2023 shows there are broadly three areas where coroner’s have raised concerns:

1) lack of policies or inadequate systems,

2) poor record keeping, and

3) issues around staff competence and training. 

From the analysis of the PFDs, record keeping issues arose relating to (a) fluid in-take charts, (b) tracking the progress of pressure sores, (c) post fall-assessments.  Lack of policies or systems failures included (d) head injury management, (e) chase up systems to primary care, (e) non- use of nursing observation charts, (f) alerts systems for residents with disabilities and those with dementia. Staff training covered a broad range of concerns: most notable, in one reported case, a nurse in charge who was unable to deal with a resident in cardiac arrest and had no knowledge that the resident’s bed was designed to allow CPR to be administered.

This snapshot mirrors the areas all care homes should review in the aftermath of the death of a resident, so as to assess whether there is a risk of a PFD being published, in the absence of a root cause analysis and service-wide changes being made.  A care home that is proactive and sets about addressing any shortfalls in advance of an inquest can reduce the risk of an adverse report being pubicly published. Our clients’ experience is that local newspapers follow up such published reports, consequently impacting on the reputation of the care home.

Coroners are not averse to addressing a PFD to the CQC (CIW, Ofsted) as well as the care home, thereby inviting regulator scrutiny and an unannounced inspection. Ideally, a care home does not want to find itself on the back foot with the coroner or the CQC (CIW/Ofsted) if it wants to maintain a good reputation and retain funding for publicly funded residents.

See examples of published Preventing Future Deaths Reports

Care Home Defence Service represents care homes and other care establishments in inquest investigations. To see how we can assist you in relation to an inquest, give us a call without obligation and in strict confidence, or use our Contact Form.

Return to our page on: Care Home Inquest Law