Summary
Coroners’ Prevention of Future Death reports (PFDRs, also known as Regulation 28 reports) provide an opportunity to understand factors contributing to mental health-related deaths.
This study examined available mental health-related PFDRs, addressing three core questions: (a) What is the overall profile of these reports? (b) What relational patterns emerge from these reports? and (c) What concerns and preventive actions do coroners highlight in these reports, and how they evolved over time?
Content
The study found that report numbers increased steadily from 2013, peaking in 2021 and then declined. Some jurisdictions, including Manchester South, East Sussex and East London, consistently had more PFDRs issued. The deceased were typically young, male and had died mainly outside hospital, most often at home; 78.0% of reports included at least one formal response from recipients, whereas 22.0% had no corresponding response available. The network analyses suggested that PFDRs seldom identified isolated issues. Coroners’ concerns changed over time, from service access and resources to inter-agency coordination and then, more recently, to risk assessment and management.
Mental health-related deaths examined by coroners arise within complex, evolving multi-sector contexts and do not frequently identify single errors. Minimising such deaths may require coordinated strategies across healthcare, social care and justice systems. Analysis of PFDRs allows identification of patterns that may inform such actions. PFDRs should be analysed routinely and patterns followed over time.
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