Regulation 28 Prevention of Future Deaths Reports

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8th September 2017

In Brief:-

Nick Fairweather explains the Coroner’s power to issue a Regulation 28 Report in Inquest proceedings and its importance in cases involving deaths in hospitals or other health care settings.

In detail:-

Coroners investigate deaths that are violent, unnatural, unexplained or occur in custody or state detention in order to establish who the deceased was, when and where they died and how they came by their death.

The Coroner also has an important additional duty to consider, in every case, whether to make a Report on Action to Prevent Future Deaths, (a PFD report). This duty arises under Part 7 to Schedule 5 of the Coroner and Justice Act 2009 and is exercised under Regulation 28 of the Coroners (Investigations) Regulations 2013.

Key features:-

  • A Coroner must compile a PFD Report if their investigation has led them to conclude that:- (1) circumstances creating a risk of death will occur, or continue to exist, in the future, and (2) action should be taken to prevent the occurrence or continuation of such circumstances or to eliminate or reduce the risk of death created by such circumstances.
  • The reports come in a set format, laid down by the Chief Coroner, within which the Coroner will state their concerns and why they think action should be taken to prevent future deaths.
  • It is not the duty of the Coroner or the report to specify what specific action might be taken.
  • Rather, the report is addressed to the organisation who might take appropriate action.
  • They have 56 days to respond by:- (1) outlining what action they have taken or will be taking or (2) explaining why no action needs to be taken.
  • That ends the reporting procedure so far as the Coroner is concerned.
  • The Report and response are also sent to:- (1) any other individual or organisation who were parties to the Inquest as interested persons, (2) anyone whom the Coroner feels may find it useful or of interest (3) to the Chief Coroner and (4) the Care Quality Commission, (in health care cases).
  • It is open to others to take action based on the Report including the Chief Coroner who will consider the report and may make additional recommendations to the recipient or wider afield to government departments and/or other organisations or individuals.
  • The Chief Coroner publishes all Regulation 28 Reports on his website.


The highest numbers of reports issued are from hospital deaths, followed by community healthcare and emergency services deaths and road deaths.

In relation to deaths in hospitals, the Chief Coroner has observed that the PFD reports frequently identify concerns over:- note taking, staffing, training, communication and the recording of medications. Mental health related deaths also feature prominently with a number of reports focussing on communication issues, particularly between different agencies and departments within hospitals and the importance of training for staff responsible for caring for patients at risk of self harm.

This certainly matches our experiences.

I believe that PFD reports are an increasingly important part of the Inquest process.

I feel that Inquests are also the best forum now for families to get answers to what happened to loved ones who died in healthcare settings.

The very existence of this PFD power tends to mean that these days hospitals who are facing a death in unexplained or untoward circumstances are likely to conduct a much more thorough and objective investigation than previously. The new duty of candour assists this process. So too does the fact that they know that the case is going to be the subject to a very full inquiry by the Coroner at an Inquest at the end of which the Regulation 28 duty applies.

Increasingly, we are seeing Root Cause Analysis or Serious Untoward Incident reports that provide full and prompt answers to families and play an important part in the Inquest proceedings.

All this assists a process that should be open and transparent and get to the truth of what occurred – achieving for families what they are always looking for in my experience: to get answers and ensure that lessons are learned and mistakes not repeated in the future.

Nick Fairweather is a specialist Law Society accredited Clinical Negligence Solicitor who regularly represents families in Inquest proceedings and civil claims arising from them.

If you or your family need the assistance of our experienced specialist team of Clinical Negligence Solicitors then please submit your case details for our consideration.