Law
coroners, there are more PFDs being issued, highlighting the fact that there has been a societal shift and increased expectations of organisations. The PFDs that have been issued since
2013 have been sent to a total of 2269 organisations. Of the top five organisations, most PFDs are made to the Department of Health and Social Care (847), with the Care Quality Commission (CQC) in fifth place, receiving 195 PFDs, according to the tracker. In the previous six months, there were a
total of 18 PFDs linked to care home related deaths, the majority of which related to the adequacy of care, record keeping and staff training. The increase in PFDs being issued by
coroners can be attributed to several factors, including growing pressures on public services, as well as increased scrutiny of organisations by coroners. The introduction of the Death Certificate Reforms in September 2024 has also led to more deaths being referred to a coroner’s office and subsequently, an increase in inquests being opened. As part of the reforms, all deaths
in England and Wales need to be independently assessed by a medical examiner, including natural deaths that did not occur in state detention or custody. This means that if a death occurs, a registered medical practitioner who knew or attended to the deceased in their lifetime should attend to establish the cause of death and issue a medical certificate (MCCD). The certificate must then be reviewed by a medical examiner, after which a death can be registered if deemed accurate. If the registrar has any concerns regarding the death, it will be referred to the coroner. The reforms were introduced to
modernise the death certificate system, but in practice it means that a death will be referred to a coroner in more circumstances,
Some media outlets have reporters sitting in coroners’ courts to listen and identify a story
including where there is no attending practitioner available, leading to an increase in cases being referred to coroners and inquests being opened in circumstances that would not have triggered an investigation before the changes were introduced.
The impact of PFD reports While a coroner has a duty to issue a PFD, their role is considered to have been performed once they have recorded their conclusions on a Record of Inquest document. This means that a coroner has no legal powers once the inquest has concluded, irrespective of whether a PFD has been issued, because they’re considered ancillary to the inquest and not their main purpose. The only requirement that an
organisation must comply with is the duty to respond to the PFD within 56 days. The coroner does not have any power to take steps if an organisation does not respond to a PFD. However, coroners are encouraged to write to the bereaved family and inform them of this, copying both the organisation and their national body or regulatory authority if applicable. All PFDs and the responses to them
are published on the courts and tribunal judiciary website. Details of organisations who have not responded are also published. So why do inquests and PFDs that lack
any criminal or civil liability hold significant risk for an organisation?
Negative publicity Inquests are public forums, which means that the press can, and often do, attend to find out
details about the death, the Interest Persons (IPs) and family. Some media outlets have reporters sitting in coroners’ courts to listen and identify a story and in some cases, family members also seek media attention to raise awareness of a situation. However an inquest comes to the media’s
attention, they can attract significant negative publicity and public scrutiny, both locally and nationally, even more so when a PFD is issued. There are numerous examples of high-profile inquests including the inquest into the death of Awaab Ishak which led to the coroner issuing a PFD to the landlord, local authority and NHS trust. This inquest led to significant negative attention for the landlord in particular, resulting in a regulatory downgrade, with wide reaching implications across the social housing sector - including increased regulation and new legislation. The wider outcomes can only be seen as positive for customers, but for the individual organisations involved, this was a torrid time.
Litigation risks While it is not within a coroner’s power to make a finding on civil or criminal liability, such as whether there was any negligence which resulted in an individual’s death, both civil claims and criminal prosecutions can follow an inquest. During the inquest there will be an ongoing
disclosure process, where the coroner will make a specific, or general, request for documents relating to the deceased and the circumstances surrounding their death. It is during this process that families, and their
July 2026
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