181.Along with answering the questions who, where, when, and how a person came by his or her death, the Coroner Service has an important role in improving public safety. It does this by making ‘reports to prevent future deaths’ (also known as ‘PFDs’ or ‘Regulation 28’ reports). The Coroners and Justice Act 2009 (CJA 2009) requires coroners to make reports where there is a risk that other deaths will occur if action is not taken to eliminate or reduce the risk. The report must be made to the person the coroner believes may have power to take such action. Coroners must not set out specific recommendations. The person or organisation must respond within 56 days (or longer if the coroner grants an extension) setting out the action taken or to be taken, and the timetable for it, or it must explain why no action is proposed. There is no process for following-up the actions proposed or to scrutinise decisions to take no action.
182.In guidance on these reports, the Chief Coroner said they:
are vitally important if society is to learn from deaths. Coroners have a duty to decide how somebody came by their death. They also have a statutory duty (rather than simply a power), where appropriate, to report about deaths with a view to preventing future deaths. And a bereaved family wants to be able to say: His death was tragic and terrible, but at least it’s less likely to happen to somebody else.’ PFDs are not intended as a punishment; they are made for the benefit of the public.
183.The Coroner Service sits within a network of bodies tasked with looking into unnatural deaths. These include
police enquiries, criminal investigations and prosecutions, investigations overseas, Health and Safety Executive (HSE) or Prisons and Probation Ombudsman (PPO) inquiries, Independent Office of Police Complaints (IOPC) inquiries or investigations by one of the specialist [transport] accident investigation bodies, the coroner’s inquest is put on ‘hold’ pending the outcome of those enquiries or investigations.
184.There are also internal investigations by public and voluntary sector bodies including health and social care trusts and universities. However, for the occasions where these external and internal investigations do not get to the truth the Coroner Service serves as a final independent arena where attention can be drawn to failings that might result in further deaths if left unaddressed. Lisa O’Dwyer, Legal Director at Action against Medical Accidents, told us:
for a family, very often the inquest is a really important investigation opportunity. Many of them will have gone through the internal processes of trusts. It may be the complaints process, or on occasions they may have gone through a serious incident review process—not always, I hasten to add—and they feel let down very often by those processes, particularly the complaints process, where they feel that the responses are either not answering the questions or are deliberately trying to obfuscate what has happened by using medical terminology and putting families off as to the truth.
185.PFD reports are often the most important part of the Coroner Service for bereaved people. Lisa O’Dwyer, told us:
They want to know the truth [ … ] that something has gone wrong and that changes are made so that it does not happen to somebody else. That is the overwhelming driving force for the people whom we represent and whom we see.
Andrew McCulloch, a bereaved parent, confirmed that “The only thing that makes sense of the loss of your loved one is that maybe lessons will be learned and the same thing will not happen to someone else.”
186.Deborah Coles, Director at Inquest, said the reports were valuable for families and for the wider public interest: “An inquest can try to ensure public scrutiny and hold people to account, but also identify false, dangerous and harmful practices, which, if put right, could prevent people from dying or being injured in the future.”
187.How tightly coroners set the scope of their investigations is important as it may determine what is, and is not, revealed during inquests and reported upon. Coroners are individually responsible for deciding which documents should be produced, which evidence will be heard at the inquest, and which witnesses give evidence. This is different from court cases where each of the parties decides what evidence they wish to put before the court. Each coroner is an independent judicial officer with wide discretion. This can lead to different approaches by different coroners. As the Chief Coroner told us the coroner decides:
The scope of inquiry must be sufficient to establish the answers to the four statutory questions, notably how the deceased person came to die. However, the inquiry will very often be wider in scope than strictly necessary to answer those questions. It is a matter of judgment for the coroner to determine the parameters of the inquiry and how far he/she will trace the causal chain leading to the death.
188.The Coroners’ Society told us local variations can affect the depth of coroners’ investigations:
local/regional variations in the practice of coroners and in the administration of the coroners service across England and Wales may result in genuine unevenness or at least the perception of unevenness. Inconsistent working practices in respect of the depth of an investigation by a coroner may vary between areas.
189.The matters to be revealed may also depend on the independence of the witnesses that the coroner chooses to call. Lisa O’Dwyer, Legal Director at Action against Medical Accidents (AvMA), raised concerns about conflicts of interest:
We certainly see other coroners who feel that they can rely on evidence given by the trust that is under investigation. That certainly raises issues of conflict on occasions without doubt. [ … ] You have to recognise that those people very often work in teams and are not independent and impartial. They may well feel the need to protect a colleague or there may be other pressures put to bear on the way in which they give their evidence. It is not appropriate to use it in those circumstances.
She raised the impact this may have on bereaved people: “Where families see that a coroner may be relying on evidence that has been given by the trust, they feel hugely let down potentially.”
190.Lisa O’Dwyer was clear that there was also good practice:
Some coroners will provide experts, and more than one if necessary. It perhaps goes to the issue of training, because not all coroners appreciate the importance that an independent, impartial medical expert witness brings to bear.
191.Deputy Chief Coroner, Derek Winter, told us of the practicalities of obtaining independent expert evidence:
Experts, of course, are expensive, so we have to be cautious with public money. If it is required, we tell the local authority of an unusual item of expenditure and they have to fund that. We would get an estimate of costs, write a proper letter of instruction to the expert, agree that with the family and the interested persons, and set the parameters of the expert’s report.
He also pointed out that an independent expert may save time and, therefore, money:
If you get an independent expert who answers all the queries of the family, you may not have to spend two days in court if the family accepts what somebody outside of that trust environment has put forward. There are difficult decisions for coroners to make in putting all those things into the balance.
192.The Chief Coroner, Judge Lucraft, told us that he has issued guidance to encourage coroners to appoint lawyers to help them navigate complex inquests:
it may well be that a number of health trusts or doctors are represented before the coroner—very often the coroner has no person to help them through quite a maze of technical terms and legal responsibility.
He told us this can help bereaved people as well as the coroner:
Part of the guidance was designed to encourage coroners, in certain types of inquest, to have a counsel or solicitor to help them, partly so that the family can see there is somebody helping the coroner who may ask questions that might otherwise have been difficult for the family to pose to the clinicians or others who had been involved in the case.
As with expert witnesses coroners will have to make out a case to their local authority for funding.
193.We received evidence that there are wide variations in the numbers of reports issued by different coroners, particularly in relation to deaths on the roads. Some coroners issue many Prevention of Future Deaths reports, some issue fewer. Victoria Lebrec of RoadPeace (which is a national charity for road crash victims in the UK) told us that “PFDs are a great initiative, but they need to be used more and they need to be used consistently.”
194.In April 2020, Chris, and Nicole Taylor, volunteers for RoadPeace analysed published prevention of future death reports for the 7 years from 2013. They found that in relation to highways safety more than 50% of coroners raised less than 3 Preventing Future Death reports over that period and 30% of coroner areas issued more than 50% of the PFD reports in this category. The differences are not simply explicable by reference to the numbers of deaths on the roads in each area. For example, the Isle of Wight reported four PFDs for 25 road deaths, while Cambridgeshire and Peterborough reported no PFDs for 253 deaths.
195.There is no process to follow-up whether actions promised at inquests or in responses to prevention of future death reports are put into effect. For example, Coroner Mr Andrew Tweddle, said:
I have written many Prevention of Future Death reports over the years [ … ] There is a lack of a proper central hub to properly monitor such reports and to follow them up and to try and secure change. It is not the function of the coroner to suggest what improvements to a situation should be, just to highlight shortcomings, and so someone else needs empowering to take matters forward.
196.Deborah Coles, Director of INQUEST, told us of the importance of following up PFD reports for families:
The very least that families are owed is that, where a report is made, those to whom it is made should make sure that they report back to families on what they have done or not done. I find it simply astonishing that we have a system that thinks it is acceptable not to keep families in the loop.
197.Lisa O’Dwyer, Legal Director at AvMA, told us that coroners’ investigations may go to waste if they are not followed up:
If you have a good, robust investigation process that the coroners’ courts certainly can deliver on, which produces a prevention of future death report, what happens is that the report is made and you get a response. There is no independent body following that up. There is no independent oversight. There is nobody policing or monitoring it, and that is almost a waste of resources.
198.Victoria Lebrec of RoadPeace thought “too many of them just simply disappear into the ether.” Several other witnesses including Birmingham and Sollihull Coroners, the Coroners’ Court Support Service, and André Rebello, Honorary Secretary of the Coroners’ Society of England and Wales, also expressed frustration at the lack of follow-up to PFD reports.
199.Lisa O’Dwyer told us that health trusts sometimes put forward action plans for the Coroner, to persuade him or her that a report is not appropriate:
A plan is presented to a coroner saying, “This is what we have done. These are the changes we are going to make,” and the coroner feels that perhaps the need to make the prevention of future death report is not quite so necessary.
She suggested that these action plans should also be followed-up:
Those action plans are as valuable as the prevention of future death reports themselves, and they too should be collated and publicised, and they really do need the same monitoring, policing and follow-up as a prevention of future death report.
200.Deborah Coles, Director of INQUEST, touched upon how to make juries’ narrative conclusions more useful too: “The other thing is that jury findings, which are often a very good overview of any systemic failings, are not collated or published anywhere, apart from when we publish them.”
201.We asked André Rebello what could be done to make reports more effective. He suggested that they should be easier to search and analyse so that coroners “can see what other reports have been issued by other coroners so we can draw the attention of other.” Lisa O’Dwyer made essentially the same point: “Trying to find how many times the same PFD [report] has been made in relation to the same trust is an extremely time-consuming and lengthy process, which for most people, even ourselves, is just not feasible to wade through.” Victoria Lebrec had similar concerns: “It is such a missed opportunity to not be able to go on to the website and search for road deaths by theme and in different local authorities to understand whether there is a particular problem with certain types of crossings on particular roads.”
202.The Australian National Coronial Information System is an example of how much better organised information from coroners’ investigations can be. It is a fully indexed online repository of coronial data from Australia and New Zealand. The data includes demographic information on the deceased, contextual details on the nature of the fatality and searchable medico-legal case reports including the coronial finding, autopsy and toxicology report and police notification of death which can be used by coroners in future investigations.
203.The Chief Coroner, Judge Lucraft, told us that he has been looking at how to improve the way reports are published but did not yet have a definite plan: “I will not be the Chief Coroner for that much longer. It is one of those jobs that I will leave to my successor.”
204.Alex Chalk accepted that getting improvements as a result of PFDs is important but suggested that care would be needed to avoid duplication with other bodies, such as the Health and Safety Executive and the prisons inspectorate:
You want to make sure that the lessons are learnt [ … ] How one goes about doing that effectively is a subject for legitimate discussion. We have certainly not closed our ears to anything. The only point that I would weigh in the balance is that one has to be mindful of avoiding duplication when there are already agencies that will be tasked with the response.
205.Dame Elish Angiolini, in her report into deaths in state custody recommended that a new office for Article 2 compliance could “oversee a coordinated, methodical and routine process around the dissemination of Coroners’ PFD reports and jury findings to all stakeholders, including (but not limited to) police forces, the College of Policing, the IPCC, and healthcare professionals.
206.The Chief Coroner, Judge Lucraft, told us that such an office could fill the gap after a coroner has issued a report and their role has come to an end. He repeated the point by almost all who provided evidence to this inquiry:
families who go through an inquest process want those lessons to be learned if there are things that can be improved so that other families don’t suffer a similar position to them. I believe that PFD reports are an extremely valuable part of the armoury of coroners. The responses are equally important, but we need to make sure that we don’t let those lessons fall between different stools and that we follow them through. I would suggest, if you wish to do so, that this Committee looks at how we make sure that the lessons flagged in these reports are followed through by Government.
207.The system for the Coroner Service to contribute to improvements in public safety is under-developed. The absence of follow up to coroners’ ‘prevention of future deaths reports’ is a missed opportunity. The Ministry of Justice should consider setting up an independent office to report on emerging issues raised by coroners and juries; and liaise with regulators, (for example the Health and Safety Executive, the Independent Office for Police Conduct, the Prisons and Probation Ombudsman, the Care Quality Commission, Highways Authorities, and Air and Rail safety bodies) and others, to follow up on actions promised to coroners and to report publicly where insufficient action has been promised or implemented. As an alternative a new Coroner Service Inspectorate could be given this role.
208.The current arrangements for publishing coroners’ reports and responses to those reports require improvement. The information published is the bare minimum and is difficult to search and analyse. The Ministry of Justice should provide funding so information about the risks to public safety discovered by coroners and inquest juries is freely available online, along with the actions that have been proposed in response. The MoJ should ensure that this information is well-organised and easily searchable.
186 Coroners and Justice Act 2009, . Details of the procedures are set out in Coroners (Investigations) Regulations 2013 ()
187 , 16 July 2013, revised 4 November 2020. The Chief Coroner has provided examples of these reports, which must be made in a specific form, in .
188 Coroners (Investigations) Regulations 2013 () regulation 29
189 , 16 July 2013, revised 4 November 2020, para 2
190 , November 2020, para 22
195 Chief Coroner of England and Wales HHJ Mark Lucraft QC (), para 38
196 The Coroners’ Society of England and Wales (), section 1(c)
205 RoadPeace (), section 3
206 Mr Christopher Taylor; Mrs Nicole Taylor (), section 1
207 Tweddle (HM Asst Coroner at Sunderland and Newcastle) (), para 3
211 Birmingham and Solihull Coroners (), para 17
212 The Coroners’ Courts Support Service (), para 3
217 [Lisa O’Dwyer]
218 [Victoria Lebrec]
219 accessed 3 May 2021
222 Now Known as the IOPC (Independent Office for Police Conduct)
223 Dame Elish Angiolini, , Home Department, January 2017, p246