Law
Navigating risks amid the rise of Prevention of Future Deaths coroner reports
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. Safeguarding and inappropriate
supervision are also common risks picked up by coroners, particularly addressing failures in monitoring vulnerable residents, responding to self-harm risks or poor multi-agency communication as well as deficiencies in training and record-keeping. PFDs trigger wider scrutiny from
regulators, commissioners and more frequently, the media. They also bring the risk of criminal and/or civil proceedings off the back of an inquest. Given the risks
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www.thecarehomeenvironment.com July 2026
associated, early engagement and careful preparation of evidence is therefore essential, not only to respond effectively to an inquest but to mitigate the risk of a PFD and the satellite actions that can follow.
Significant increase in PFD Reports Since 2020, there has been a steady increase in the number of PFDs published by coroners in England and Wales, with a 97 per cent increase to 614 in 2025. This was a minor drop from the 682 that were made in 2024, however there was also a decreasing number of deaths being reported to coroners, with the lowest level referred in 2024 since records began in 1995. Statistically, it’s clear that while there are fewer deaths being referred to
Philip J Openshaw -
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