Editorial: The Guardian view on the coroner’s role: if deaths can be prevented, they should be (8 October 2024)

Summary

The family of Maeve Boothby O’Neill, who died aged 27 after suffering from myalgic encephalomyelitis (ME) for many years, is not the first to reach the end of an inquest only to be faced by uncertainty regarding its results. The coroner issued a prevention of future deaths notice (PFD) addressed to Wes Streeting and five health organisations, including NHS England. This criticised the lack of specialist care and training for doctors, and raised concerns about clinical guidelines and nutrition. But while there is a legal obligation on any body in receipt of such a notice to respond within 56 days, there is no requirement on them to take any action at all.

Prevention of future deaths notices are a crucial part of the inquest system. They exist so that as well as investigating the causes of violent or unexplained deaths, coroners can seek to ensure that their findings are learned from. Given that these documents deal with risks to life, and are the outcome of a legal process, they obviously ought to be heeded.

Unfortunately, the present system does nothing to ensure that this happens.