Preventable Deaths Tracker

A platform to explore concerns raised by coroners to prevent future deaths

About

What is a PFD report?

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:

  1. Coroner’s write PFDs and send reports to specific individuals or organisations;
  2. Addressess respond to the coroner regarding concerns raised (within 56 days under Regulation 29), outlining actions taken or proposed; and
  3. Actions to prevent deaths are implemented.

Why is this research important?

In the UK, 22.5% of all deaths were considered avoidable in 2019. Yet only 526 PFDs were published in 2019. Wide communication of these PFD reports could have reduced such avoidable deaths.

While many recognise the important lessons outlined by coroners in PFDs, the lack of communication of these lessons and the insufficient auditing of the statutory requirement of responding to PFDs and taking action limits their use. The Preventable Deaths Tracker is trying to change this.

The work we do

  1. Research
    1. designing studies to answer essential questions for public safety
    2. maintaining and updating the Preventable Deaths Database
  2. Education
    1. teaching university students on study design and research methods, providing students with the opportunity to conduct their own research study using the Preventable Deaths Database
    2. training on using the Preventable Deaths Database, writing PFDs, and building digital systems to streamline processes
  3. Communication
    1. writing scientific reports and academic publications
    2. using social media and engaging with the media
    3. developing the Preventable Deaths Tracker

How can I get involved?

If you’d like to get involved in this research or the funding of our work, please get in touch: georgia.richards@kellogg.ox.ac.uk

Our team

This project is led by Dr Georgia Richards, with support from a team of academics, scientists, clinicians, and coroners. You can find out more about our team below:

We’d also like to acknowledge the time and work of many students who have contributed to or led research projects, including Ali Ains, Grace Anthony, Dr Maja Bilip, Simran Bilku, Milan Campion, Jessica De La Haye, Francesco Dernie, Nicholas DeVito, Harrison France, Joshua Loo, Louis Odgers, Laura Seeney, Bethan Swift, and Dr Elizabeth Thomas.

Funding

Dr Georgia Richards was awarded an Engagement and Dissemination grant (2020) and a Seedcorn grant (2021) from the National Institute for Health Research (NIHR) School for Primary Care Research (SCPR) to fund the initial development of this website. At present, we have no core funding to support the research, data management, education, training, dissemination or development of the Tracker.