Failure to act on coroners’ advice blamed for thousands of deaths

One woman who tracks preventable deaths says the failure to take action when inquests identify threats to life is ‘mind-blowing’.

Thousands of deaths could be prevented every year if public bodies took action over concerns highlighted at inquests. Almost 82,000 deaths in 2022 were recorded by the Office for National Statistics in England and Wales as “preventable”, meaning they could have been avoided “through effective public health and primary prevention interventions”.

Analysis by the Preventable Deaths Tracker project at King’s College London revealed that 1,495 Prevention of Future Deaths reports (28 per cent of the total) have not received any responses and another 741 (14 per cent) received only partial responses. Once reports are issued there is no official monitoring of responses or whether any action follows. Coroners have no powers to ask further questions or request progress reports on reforms.

The founder of the Preventable Deaths Tracker, the epidemiologist Dr Georgia Richards, said it was “mind-blowing” there was no system to disseminate learning from inquests. “Across 5,000 reports over the last 12 years, it is impossible to know anything about what action that might or might not have been taken following a coroner’s report,” Richards said. "People think there must be a system that’s protecting us. We assume that if you were in government that you would want to know what’s happening in these death investigations. But the system doesn’t work, it’s a waste of time. There are very few PFDs that have led to meaningful change and often it’s not the PFD that triggered it. Change comes from additional factors like change in leadership of the organisation, huge media scrutiny or dedicated families.”

Peter Thornton KC, chief coroner from 2012-16, said: “First, there are not enough coroners writing these reports. Secondly, they can’t force a response. Thirdly, they can’t follow up a response. Fourthly, they can’t force action — they can only suggest that an area of action is considered. And last, there’s no national follow-up, there’s no co-ordination.” Thornton urged reform through the creation of a national coroner service. The inquest system is jointly managed by the judiciary, local councils and the police. It is poorly funded and has big backlogs: 1,685 bereaved families are waiting longer than two years for hearings.

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Source: The Times, 14 January 2025 (paywalled)

Related reading

• Five recommendations to prevent future deaths: Written evidence for the Parliamentary follow-up Inquiry to The Coroner Service (Georgia Richards, 9 February 2024)
• Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS (7 April 2022)