Introduction
Few aspects of an inquest attract as much attention, or perhaps as much misunderstanding, as a Prevention of Future Death report (often shortened to a “PFD Report”).
- For families, a PFD Report can represent meaningful change and help to ensure mroe families don’t go through anything similar.
- For public bodies, it can carry reputational and regulatory consequences and be embarassing
- For legal practitioners, it requires disciplined and evidence-based submissions that are focused on the law.
The statutory foundation lies in Schedule 5 paragraph 7 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. (As such, PFD Reports are also sometimes called “Regulation 28 Reports”. They are the same thing)
Understanding the criteria for making a PFD Report is essential.
The Statutory Test
Schedule 5 paragraph 7 of the Coroners and Justice Act 2009 states:
(7) (1) Where —
(a) a senior coroner has been conducting an investigation under this Part into a person’s death,
(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 coroner must report the matter to a person who the coroner believes may have power to take such action.
[Bold emphasis added]
So a Coroner must make a report where:
- An investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or continue to exist; and
- In the Coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances.
The power is always preventative – never punitive.
Causation and Evidential Foundation
A PFD Report cannot be made merely because a failing is identified. The concern must arise from the evidence heard in the investigation and must relate to a risk of future death.
The Coroner must remain strictly within the evidence arising from the investigation.
This ensures that PFD reports maintain their statutory purpose: prevention, not public inquiry or blame.
So:
- A risk identified must be evidence-based, but it does not have to have been a feature that led to the death the inquest is considering.
- For example, a builder died after being struck by a vehicle on a building site. During the inquest, other employees gave evidence that there was also poor scaffolding in place. The Coroner may feel that the scaffolding issue is a cause for concern and action should be taken, even if they are satisfied that the driving and road layout systems were safe.
- It must relate to a risk of death, not merely harm.
- This is a relatively high threshold. If solely further harm (not further death) is anticipated, a PFD Report is not appropriate.
- It must not amount to a roving policy review or a further opportunity to gather evidence.
- PFD Reports are not used to conduct a public inquiry.
Article 2 Inquests and PFD Reports
Where Article 2 ECHR is engaged, Coroners scrutinise systemic issues in greater depth.
However, Article 2 does not lower the statutory threshold for a PFD.
The Revised Chief Coroner’s Guidance No.5 Reports to Prevent Future Deaths notes at §46:
In an Article 2 inquest the PFD may complete the state’s duty to inquire fully … but a PFD is not mandatory simply because an inquest is an Article 2 inquest.
Making Submissions
Some Coroners (perhaps around 35%) do not habitually invite submissions from Interested Persons concerning PFD Reports, as they view this as a matter of fact rather than law, which is solely for them to determine.
Submissions inviting a Coroner to make a PFD Report should clearly identify:
- The specific circumstance revealed by the evidence.
- The mechanism by which it gives rise to a risk of further death.
- Why action remains necessary to prevent recurrence.
Measured tone is critical. The objective is prevention, not adversarial positioning.
Conclusion
A PFD report is a powerful statutory mechanism. But it is confined to:
- Evidence arising from the investigation
- Risks of future death
- Preventative, not punitive, purpose
Careful forensic framing often determines the outcome.
Advice on Prevention of Future Death Reports
If you are seeking to invite a PFD Report, clear and disciplined submissions are essential. If you would like to discuss PFD reports or systemic risk findings in an inquest, please contact me here.