Coroners have been issuing an increasing number of statutory requests to providers to set out how they will mitigate safety concerns following an inquest into a death in a care home. Charlotte Greatorex and Narin Masera explain the context – and what this means for care leaders.
In the aftermath of a death, a coroner may conduct an inquest, which is a public, fact-finding investigation to establish who has died, when, where, and how the death occurred.
As part of this investigation, the coroner has a duty to issue a Prevention of Future Deaths Report (PFD) if, during an investigation, they identify a concern that creates a risk of future deaths. This could be related to the death, or something totally unrelated which the coroner has identified through their investigation. The coroner must notify the concern to the relevant organisations who are then under a statutory duty to respond within 56 days, setting out the steps taken or proposed, or explaining why no action is necessary.
PFDs have steadily been on the rise over the last 20 years and can arise in a wide range of contexts. They are frequently made in the care and support sector with common themes of inadequate risk assessments and/or care plans, poor fire risk management or failure to escalate in response to a deterioration of health.
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