Law
legal advisors, obtain and analyse evidence regarding potential acts or omissions that may have contributed to the death which can lead to proceedings. Examples of civil actions that may result
from a death in a care home can include Human Rights Act claims and negligence claims, including gross negligence and professional negligence.
Regulatory action Inquests often pique the interest of regulators, such as the CQC, Health and Safety Executive (HSE), and Regulator of Social Housing. While it is rare for the social care regulator to be directly involved in an inquest, they may be invited to attend or be made aware of an outcome. Equally, where an inquest involves anything related to the watchdog’s regulations such as a breach, the party concerned should be keeping it in the loop. As above, the CQC are the top fifth
recipient of PFDs within England and Wales. These often refer to the adequacy of care that an individual has received within a care setting. The regulator is also sent copies of PFDs by the coroner when an order has been made against a relevant organisation. The HSE are known to receive PFDs from
coroners on a range of health and safety matters. Recent examples relate to a lack of guidelines for fire escapes, for example, and fire safety responsibilities.
Mitigating risks When a person dies, care providers may face regulatory scrutiny. Upon notification of an inquest conclusion or a PFD, regulators may decide to investigate and take regulatory action against an organisation where the inquest has resulted in serious concerns relating to the service. Taking early, proactive steps can
significantly reduce the risk of a PFD report or prosecution.
Reducing the risk of a PFD report As mentioned above, a PFD report is issued when the coroner believes similar deaths could occur again, setting out shortfalls, concerns and failings. To mitigate this risk and avoid a
PFD report being issued, providers must demonstrate meaningful learning and improvement. This starts with identifying any shortfalls in processes, training, staff curiosity, communication, and record keeping, to name a few key areas. Any review should conclude with recommendations for improvement,
setting clear actions, timeframes for implementation and accountability. However, providers should be cautious
due to ongoing disclosure obligations during an inquest and seek legal advice at an early stage to support with any review. Coroners are often reassured when
they see evidence of honest reflection, responsibility and organisational learning.
The involvement of the CQC When a death occurs in a regulated setting, Regulation 16 of the CQC (Registration) Regulations 2009 requires providers to notify the regulator of a death without delay. Prompt notification demonstrates
transparency, avoids regulatory breaches, and reduces the risk of enforcement action or prosecution. Care homes should maintain clear internal processes to ensure timely submission of statutory notifications to mitigate against any breaches. It goes without saying that clear, consistent
communication with the CQC is essential. Providers should keep the regulator informed about the immediate safety steps taken, the progress of internal investigations, key findings and organisational learning and the implementation of changes. Engaging openly supports regulatory confidence and reduces the risk of escalation.
Minimising the risk of prosecution As mentioned above, when someone dies, depending on the circumstances, there can be a risk of prosecution by the HSE, Fire service and/or police. A PFD report can also contribute to the reopening of any previous investigations. To reduce risks of enforcement action
ever being necessary, care homes should maintain uptodate, comprehensive risk assessments, effective and regularly refreshed staff training, strong supervision and oversight of staff and residents, regular maintenance and environmental safety checks, as well as a culture of openness, where staff can report concerns or nearmisses without fear. These measures not only support resident safety but also demonstrate responsible management and governance. When a death occurs, especially in
unexpected circumstances, providers should take immediate action to resolve any urgent safety concerns, preserve records and potential evidence, begin a structured internal review (consider if you need legal support at this point), support staff involved in the incident, and seek early legal advice.
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www.thecarehomeenvironment.com July 2026 Legal advice at an early stage helps
ensure staff understand their rights during interviews and helps the organisation manage parallel investigations effectively. It also ensures consistent communication with stakeholders and reduces the risk of missteps that could lead to enforcement action or prosecution.n
Charlotte Greatorex
As an associate at Devonshires Solicitors, Charlotte acts for registered providers in Article 2 and non-Article 2 inquests. She has experience of dealing with inquests relating to the provision of general needs housing as well as care homes and specialist and specialised supported housing for vulnerable people.
Narin Masera
Narin is a solicitor at Devonshires Solicitors and has advised a range of clients on complex multi-agency inquests. She has extensive experience on working on Article 2 inquests and has advised registered providers of both general needs housing, specialist supported housing and charities.
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