A prevention of future deaths report is a coroner's formal statement about a risk of other deaths. It says that something revealed by an inquest gives rise to that risk. Most people call it a PFD report or a regulation 28 report. It goes to whoever the coroner believes has power to act. That may be a trust, a national body, a GP practice or an individual clinician. Whoever receives it, the report and your response are likely to become public. So the response is a public document, and you should write it as one.
When a coroner must report
The duty comes from paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009. It applies where anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur or continue. The coroner must also consider that someone should take action. In that case, the coroner must report the matter to a person the coroner believes may have power to take that action. The word is must. When the conditions hold, the coroner has no discretion to stay silent.
Regulation 28 of the Coroners (Investigations) Regulations 2013 adds the procedure. Before making a report, the coroner must consider all the documents, evidence and information that the coroner thinks relevant. The coroner must send a copy to the Chief Coroner and to every interested person who, in the coroner's opinion, should receive it. After that, the Chief Coroner may publish the report or a summary of it.
What the Chief Coroner's guidance says
The Chief Coroner's Guidance No. 5, first issued in 2013 and revised on 4 November 2020, sets the approach coroners take. It says coroners do not intend reports as a punishment, and that they make them for the benefit of the public. Nor should a report apportion blame. The guidance describes a report as a recommendation that someone should take action. So the choice of remedy is yours, because the report does not say what that action should be. The guidance expects coroners to send a report within ten working days of the end of the inquest. It also records that once a report has gone, the coroner has no power to withdraw it.
The guidance also states that the Chief Coroner publishes as many reports as possible on the judiciary website, subject to limited redaction. It adds that a person includes an organisation. A report addressed to your practice or partnership is a report you must answer.
Your duty to respond
Paragraph 7(2) of Schedule 5 requires anyone who receives a report to give the coroner a written response. Regulation 29 sets its content and timing. The response must contain details of any action taken or proposed, with a timetable. Otherwise it must explain why you propose no action. It must reach the coroner within 56 days of the date the coroner sends the report. The coroner may extend that period, even on an application made after the time has run out. But an extension is not a right, so ask early if you need one.
The coroner sends the response to the Chief Coroner and to interested persons, and the Chief Coroner may publish it. You may make written representations about the release or publication of your response. But regulation 29(9) requires you to make them no later than the time you provide the response. If your response refers to a colleague's health or to patient details, make those representations with it.
Writing a response that holds up
A good response takes each matter of concern in the order the coroner listed it. For each, it says what has changed and who is responsible. It also gives the date you made or will make the change, and how you will know it has worked. Where you decide that no action is necessary, it explains why with evidence, for example an audit or a policy already in force. Avoid arguing with the coroner's findings of fact. The inquest is the place for that, and a response that reargues the hearing reads poorly to the family and to the GMC.
If you work in a practice or a trust, agree the response with the organisation. Even so, read the final text yourself. A sentence that frames a system failing as your personal oversight will sit on a public website under your name.
The report and the GMC
A PFD report is not a finding of fitness to practise, and its purpose is prevention rather than blame. Even so, paragraph 99 of Good medical practice (2024) requires you to tell the GMC without delay if an official inquiry has criticised you. The GMC's reporting guidance lists a coroner's inquest as an example of such an inquiry. The inquest or the report may criticise you on serious matters that call your fitness to practise into question. If so, take advice on a self-referral to the GMC. Keep the report, your response and the evidence of the changes made. Those documents show insight and remediation if the GMC asks.
If you are a nurse, dentist, pharmacist or other healthcare professional
The coroner's duty under regulation 28 does not depend on the profession of the person concerned, so a report may be sent to a nurse's employer, an ambulance trust or a pharmacy as readily as to a doctor's practice, and the regulator that reads it may be the NMC, the HCPC or the GPhC rather than the GMC. Our pages for nurses and midwives, pharmacists and HCPC professionals explain their processes.
Eloquia acts on PFD reports on our inquests and NHS disciplinary track. If the coroner is considering a report, we help you show what has changed since the death. For each stage you pay a fixed fee, stated plus VAT, which we quote once we have seen the papers. That fee includes a specialist barrister whom we involve from the outset, and our fees and funding page explains how staged payment works.
If a coroner has sent you a regulation 28 report, note the date the coroner sent it and diary the 56 day deadline. Write to the coroner now if you need longer. Then draft your response against each matter of concern in turn.
Sources
- Coroners and Justice Act 2009, Schedule 5, paragraph 7: Action to prevent other deaths
- Coroners (Investigations) Regulations 2013, regulation 28: Report on action to prevent other deaths
- Coroners (Investigations) Regulations 2013, regulation 29: Response to a report on action to prevent other deaths
- Chief Coroner, Revised Chief Coroner's Guidance No. 5: Reports to Prevent Future Deaths (revised 4 November 2020)
- GMC, Good medical practice (2024), Domain 4: Trust and professionalism
- GMC, Reporting criminal and regulatory proceedings within and outside the UK
