Learning from Coroner's reports

Summary

When a patient dies because of preventable avoidable harm it is crucial that we learn from the event and implement changes to ensure it does not reoccur. Implementing the findings and recommendations of Coroner’s Prevention of Future Deaths (PFD) reports can play a key role in this. This blog reflects on a recent discussion at a Patient Safety Management Network (PSMN) meeting about PFD reports and how their insights can be used for learning and improvement.

The PSMN is an informal voluntary network for patient safety managers in England. Created by and for patient safety managers it provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. You can find out about the network here.

Content

What are PFD reports?

Coroners have a duty to decide how somebody came by their death and also, where appropriate, to report about that death with a view to preventing future deaths.[1] [2] These reports follow a set template format and are issued by the Coroner to any person or organisation where, in their opinion, action should be taken to prevent future deaths. These reports are made publicly available online and the persons/organisations involved having a duty to respond within 56 days.

PFD reports relating to deaths in health and social care settings can help to identity what went wrong and the actions needed to prevent a similar incident reoccurring. They also may provide points of learning that are applicable beyond the organisation in which this took place which can inform wider system learning. On the hub we routinely add PFD reports that concern patient safety issues and learning.

Patient Safety Managers’ perspective

In their meeting last week, PSMN members shared their experiences about responding to PFD reports, highlighting that there are vastly different approaches to engaging with Coroners across NHS organisations. It was noted that responding to these reports can be quite complex, due to their sometimes wide and multi-organisational remit. There was also a discussion about how Coroners will consider whether to issue a PFD if they consider action has already been taken. In some cases, where a PFD is subsequently not issued, it was suggested that this could unintentionally result in learning remaining siloed in the organisation where the death occurred, rather than applied more widely.

Discussing how different Trusts approach responding to Coroners investigations and PFD reports, a number of key points of good practice were highlighted:

• Importance of establishing an effective, open, and transparent relationship with your local Coroner.
• Value of demonstrating to the Coroner the Trust’s awareness and action on specific issues through the use of thematic reviews, e.g., looking specifically at deaths by suicide.
• Using opportunities this process presents for learning and collaboration across a patient pathway, connecting across the Integrated Care System.
• Crucial role of debriefing after an inquest, ensuring learning is shared and that there is a rapid review of immediate actions.
• Providing the Coroner with information about Serious Incidents and previous relevant information where appropriate, to ensure transparency and help inform their considerations.
• Importance of providing support for staff in their attendance at Inquests so that they know what to expect.

PSMN members talked about the valuable role that PFD reports can play in highlighting patient safety issues that may not have previously had sufficient organisational understanding or commitment. They emphasised the importance of organisational commitment to these processes, with the need for senior leaders to attend inquests and understand the measures being taken to act on the Coroner’s findings.

They also considered how the processes currently in place may change as a result of the new Patient Safety Incident Response Framework (PSIRF) guidance on how to investigate incidents of unsafe care, and the importance of this being picked up in national policy and guidance, not just at a local level.[3]

Implementing actions and sharing learning

PFD reports provide a wealth of insights and learning; however, the key challenge remains ensuring that we utilise these to their full extent to improve patient safety and care. At Patient Safety Learning we believe that more could be done on at a regional and national level to ensure that NHS Trust’s are supported in implementing actions from PFD reports and sharing learning and outcomes more widely. In a previous blog, we suggested some key actions we believe are needed to help address gaps in the current system:

• Analysis reports – Integrated Care Systems carrying out annual thematic reviews of all PFD reports, Serious Incident reports and associated safety action plans, which could inform future commissioning safety action plans and Care Quality Commission insight.
• National oversight – establishing a clear system of oversight for monitoring the implementation and effectiveness of PFD report recommendations.
• Improve accessibility – creating a central repository for all PFD reports, Serious Incident reports and associated safety action plans in one database searchable by actions and themes.
• Standards – putting in place patient safety standards for Integrated Care Systems, with requirements on individual trusts, primary care networks and service providers to share learning from these reports.
• Annual report – publish an annual report on themes for learning and action from PFD reports and Serious Incident reports.

References

1. The Coroners. (Investigations) Regulations 2013, Part 7: Action to prevent other deaths, 2013.
2. Chief Coroner. Guidance No. 5: Reports To Prevent Future Deaths, Last revised 14 January 2016.
3. NHS England and NHS Improvement. Patient Safety Incident Response Framework, Last Accessed 5 March 2022.