Summary
In England and Wales, law requires that coroners issue a Prevention of Future Death (PFD) report when they believe that action should be taken to prevent future deaths. Prevention of Future Death reports therefore provide an opportunity to learn and prevent harm. This study in the Journal of Patient Safety and Risk Management thematically analyses PFD reports received by the National Institute for Health and Care Excellence (NICE) along with the organisation's response. The study provides insight into the PFD report practices of a national guidance producing and standard setting body in the UK, as well as supporting system-level understanding of current practices in relation to PFD reports. However, the authors note that there are no means to assess if the Chief Coroner's Office and the wider safety system considered NICE's responses adequate or whether the actions taken were effective.
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