When a coroner becomes aware of circumstances that put people at risk of people dying, they have a duty to take action.
They issue a prevention of future deaths (PFD) report, which means they report the matter to whoever they believe has power to take action to change things. This could be a person or organisation, such as a local authority, NHS trust or government department or agency.
It is up to the coroner to issue a PFD report. They consider what changes they have been told have happened since the person died or are being planned.
Even if changes have been made locally, if coroners believe deaths may happen elsewhere in the country, they may issue a PFD report to national organisations or bodies, such as the Department of Health and Social Care.
Each report includes details of who the person was, when their inquest took place and what the investigation found. There are sections in the report that look at the circumstances of the death and the matters of concern.
Anyone sent a report must respond to the coroner within 56 days to say what actions they have taken or will take. They have to include a timetable for action and, if they do not believe they need to act, they must explain why.
Reports and any responses received are uploaded onto the Courts and Tribunal Judiciary website.
Each year, about one in every 100 inquests that conclude leads to a coroner issuing a PFD report.
Not many relate to learning-disabled and/or autistic people. There may have been more but the system does not ask coroners to include whether someone had a disability.
Of the 569 PFD reports issued in 2023, 29 related to the deaths of learning disabled and/or autistic people.
Among these, five relate to learning-disabled people who had died after staff supporting them had not followed the advice in speech and language therapy plans, care plans and risk assessments.
The reports can be useful as a way to understand why people are dying and what changes can be made to stop that.
Before he retired, former chief coroner HHJ Thomas Teague KC said in his annual report: “PFDs are very important and can achieve a great deal when properly used, but the prevention of future deaths is not the primary function of a coroner’s investigation, which is to focus on the death of the deceased person. As judges, coroners cannot make changes to avoid future deaths; their role is simply to point out risks.”
It is hard to know whether these reports are leading to change. It is the job of coroners to investigate deaths and point out risks; they cannot make changes themselves to prevent future deaths. Once they issue a report, the coroner no longer has any power or role to play.
No one has the job of checking responses received to PFDs or the responsibilities to check that respondents have made the changes they have promised.
Inquest, a charity concerned with state-related deaths, is campaigning for a body to be established to collect PFD reports, note what they say and follow up on actions.
We know many of these reports issued concern the same problems so, even if they have led to some improvements, they have not stopped all of these deaths.
Mia Gauci-Lamport
Mia Gauci-Lamport was 16 when she died in September 2023. At her inquest, her family said she would give the “warmest of hugs, the cheekiest of smiles and the sloppiest of kisses”.
Gauci-Lamport had a learning disability and epilepsy. In July 2020, she had moved into the care of the Children’s Trust in Tadworth (TCT), where she lived and went to school.
The assistant coroner for Surrey, Dr Karen Henderson, held an inquest in July 2024 and issued a PFD in October. This listed three areas of concern:
- Lack of appropriate monitoring of Gauci-Lamport during the night
- Medical care provided to her
- Senior management at the Children’s Trust, Tadworth.
The coroner said some of the concerns were identical to those she had issued following an inquest into another death at TCT.
“The lack of a robust and adhered-to care plan for night observations for Mia mirrors the same concern in the PFD report I issued following the Inquest touching on the death of Connor Wellsted at TCT in 2022,” she said.
“The independent investigator commissioned by TCT highlighted ongoing clinical governance limitations including the initial management and investigation of Mia’s death, delay in fulfilling duty of candour obligations, ongoing staff training, ensuring robust procedures were in place alongside regular audits of clinical practice. These are the same issues highlighted in the PFD report I issued touching on the death of Connor Wellsted two years previously.”
No one has the job of checking responses to these reports or that respondents have made the changes they have promised
After the inquest, the trust said it was “determined to understand any lessons we can draw from Gauci-Lamport’s sad death. We are working together with all relevant authorities to enhance our delivery of high quality, safe and effective care and learning for the children in our care.”
The PFD, which was dated 14 October 2024, was sent to NHS England, the Department of Health and Social Care, the TCT chief executive and medical director and care regulator the Care Quality Commission.
By the end of November, no responses had been received.
Peter Seaby
Peter Seaby was 63 when he died in 2018 at the Oaks and Woodcroft care home in Mattishall, Norfolk, run by the Priory Group.
His family got an earlier inquest ruling – that he had died of natural causes – overturned. His second inquest was in 2023.
Seaby had Down syndrome and had always lived happily with his family, with his sister Karen as care provider. He was moved into care for respite and became a permanent resident against his family’s wishes. Six months later, he died.
Jacqueline Lake, the senior coroner for Norfolk, found that inadequate preparation of his lunchtime meal and supervision possibly contributed to his death.
The coroner issued a PFD as she had concerns about the care provided to people still living in the care home.
“Evidence was heard at the inquest of the ‘informal approach’ taken with regard to arrangements as to who would provide supervision of residents, including on a one to one basis and who would cook and prepare their meals, including those residents who were subject to a specific speech and language therapy dietary plan,” she said.
Evidence was also heard of steps that had been take since the death to provide written staff rotas for such matters, prepared by team leaders and deputy managers.
His provider had still not undertaken an internal review into the unexpected death
However, despite this, evidence was also heard at the inquest from staff who continue to provide care the home, who referred to providing care on an “informal basis” and saying this “works”.
The coroner raised concerns about levels of staffing and the fact his care provider had still not undertaken an internal review into the unexpected death.
In their April 2023 response to the coroner, the Priory Group said: “In respect of taking this review forward, our operational management team are to now closely consider the findings of your Inquest and other information made available about the tragic incident involving Mr Seaby.”
No explanation was offered for why this had not taken place in the five years since Seaby had died.
In August 2023, the Care Quality Commission found the service required improvement. Regarding mealtime supervision, it said: “Incidents where people had become agitated around mealtimes put people at risk and these risks had not been sufficiently assessed and explored. For example, 1 person grabbed at other people’s food and was at risk of choking.
“A high number of incidents were recorded to have taken place in the dining room and it was unclear what strategies were in place to reduce the level of incidents.”
