In healthcare settings, when accidents occur that result in a fatality it is imperative that lessons are learnt from these tragic events and action is taken to prevent recurrence.
Paragraph 7 of Schedule 5, Coroners and Justice Act 2009, provides coroners with the duty to make reports to a person, organisation, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths. The reports are restricted to matters which were causative of the death in question. A report of the PFD is sent to the deceased’s family and is made public on the Courts and Tribunals Judiciary website.
Under Section 29(1) of the Coroners (Investigations) Regulations 2013 a person or organisation must respond to the PFD within 56 days, or longer if the coroner grants an extension. The response must detail the action taken or to be taken, or it must explain why no action is proposed. The Chief Coroner can publish responses to PFDs on their website and, therefore, this should be seen as an opportunity for the healthcare providers to provide as full as a defence as possible.
A copy of the PFD report is sent to the CQC and this may initiate an unannounced inspection to investigate any concerns raised in the report. As such, health and social care organisations are keen to avoid a PFD where possible. Organisations must, therefore, ensure that any potential failings connected with a death are properly investigated and any action plans are completed and evidenced fully to address the concerns raised.
In the Chief Coroner’s revised Guidance Note on PFDs it is stated that “PFDs are not intended as a punishment; they are made for the benefit of the public”. As such, PFDs should be seen as a powerful mechanism by which to improve public health, welfare and safety. They seek to drive up industry standards and ensure that lessons are learnt from serious wrongdoings.
For more information, please contact Claudia Swindale, File Handler Assistant – Crime & Regulatory
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