Under The Coroners Rule 1984, coroners in England and Wales have a duty to report and communicate a death when the coroner believes that action should be taken to prevent similar deaths. In 2013, these reports, named Prevent Future Deaths or PFDs (previously Rule 43), became mandated under Paragraph 7 of Schedule 5 of The Coroners and Justice Act 2009, and regulations 28 and 29 of The Coroners (Investigations) Regulations 2013. The PFD system has three processes:
- Coroner’s write PFDs and send reports to specific individuals or organisations;
- Addressess respond to the coroner regarding concerns raised (within 56 days under Regulation 29), outlining actions taken or proposed; and
- Actions to prevent deaths are implemented.
Many recognise the important lessons outlined by coroners in PFDs, but concerns have been raised regarding the lack of wider communication of these lessons and insufficient auditing of the statutory requirement of responding to PFDs and taking action.
We have created this website – the Preventable Deaths Tracker – and the Preventable Deaths Database to collate and display the data from PFDs in a visual, filterable, and searchable format that others can use. We have also launched the Coroners’ Concerns to Prevent Harms series in BMJ Evidence Based Medicine to disseminate important lessons that serve patient safety and prevent similar deaths.
Some summary statistics
As of 12/09/2021, the judiciary has uploaded 3709 reports. 1416 of them are unresponded to. 2293 of them have received at least one response. And 1368 have received the expected number of responses or more.
The expected number of responses is calculated by finding the number of recipients of a report. In some cases, interested parties not initially named as respondents also respond. Due to an absence of machine-readable data, it is difficult to devise more informative schemas that remain robust.
Figure 1: reports by month
Figure 2: response rates
Figure 3: reports by area