If we can’t learn from errors, families relive tragedy for nothing

It was in a coroner’s court last year, at the inquest into the death of his 27-year-old daughter Maeve, that Sean O’Neill heard the most dispiriting words. The coroner, Deborah Archer, said she was going to write a prevention of future deaths (PFD) report, highlighting to the NHS and other agencies areas of concern. Then she added: “I write a lot of these reports, and often nothing happens.”

Maeve died after suffering for half her life with myalgic encephalomyelitis (ME), a post-viral condition that is not well understood, inadequately researched and which doctors often refuses to recognise or treat.

Sean's aim was to use the media to highlight what happened to Maeve and raise awareness of the plight of the hundreds of thousands of people whose lives are limited by ME and similar conditions. His second aim was to convince the coroner to write a PFD report and point out areas in healthcare, medical research, education and training where action could be taken that might prevent further such deaths.

The written responses to Archer’s PFD report have been underwhelming. The public health minister, (the recently resigned) Andrew Gwynne, promised an NHS delivery plan. NHS England said it would do a “stocktake” of ME services, even though there had been evidence at the inquest that such services are scarce, and in the cases of severely ill patients, “non-existent”. The Medical Research Council said it “recognises the unmet clinical need for better diagnosis and treatments for people living with ME” but defended its record to date.

In 2023 there were more than 1,600 inquests that had been open for more than two years; often these are the most difficult cases, yet bereaved families face being repeatedly traumatised by every preliminary hearing and legal letter.

As in Maeve’s case, the best hope for a family is that a PFD report points the way to reform. A coroner is not allowed to recommend, only suggest. Yet only rarely are these reports written. 

Those coroners who do write reports often find their suggestions ignored. Just under 40% of the 5,532 PFD reports published since 2013 have received no responses. There is no other section of the legal system in greater need of reform. There should be a national coronial service, more PFD reports should be written and lessons should be disseminated. What is the point of investigating avoidable deaths — of making bereaved families relive their trauma, of spending millions of public pounds — unless we are prepared to learn how to avoid similar fatal errors?

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Source: The Times, 23 February 2025