Question to the Ministry of Justice:

To ask the Secretary of State for Justice, what steps have been taken in response to receiving Prevention of Future Death reports.

Coroners do not make recommendations as part of their inquest findings. However, where a coroner investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and the coroner considers that action should be taken to prevent future deaths, they have a statutory duty to issue a Prevention of Future Deaths (PFD) report to a person (including an organisation, public body, Government department or private company) that may have the power to take such action.

Recipients are required to provide a written response to the coroner within 56 days, or within any extended period agreed by the coroner, setting out action taken or proposed, or explaining why no action is proposed. Reports and responses must be sent to the Chief Coroner and are generally published and available at: https://www.judiciary.uk/?s=&pfd_report_type=&post_type=pfd&order=relevance.

These reports have been intentionally placed into the public domain since July 2013 as part of the Government and the judiciary’s commitment to open justice, so that coroner concerns can be understood, analysed and utilised to improve learning by recipient and other interested organisations, as well as by academics and others with a relevant interest.

The Government recognises the important role that PFD reports play in highlighting circumstances where action may be required to reduce the risk of future deaths and promoting organisational learning. However, whilst the Lord Chancellor has responsibility for the legislative framework governing the coronial system, the Ministry of Justice does not centrally assess, monitor or record the implementation of actions arising from individual PFD reports across Government and does not hold centrally the number of PFD reports received by government departments since 2013, nor the number of reports with outstanding responses. Responsibility for considering concerns raised by coroners, determining any appropriate action and responding to the coroner rests with the organisations and departments to which reports are addressed.

PFD reports are sent directly to the relevant recipients, and as above, are published by the Chief Coroner along with responses. Information on reports received and responses provided can also be obtained from individual recipients. Since 2025, the Chief Coroner has also published periodic lists of reports for which no response has been received by the relevant coroner's office.

The Ministry of Justice keeps all aspects of the coronial system under review and continues to consider evidence and proposals to improve learning from deaths. However, the Department currently has no plans to introduce a national learning from deaths strategy. This reflects the fact that responsibility for preventing avoidable deaths and reducing harm sits across a wide range of government departments, agencies and bodies, each with their own specialist expertise, statutory responsibilities, policy levers, governance arrangements and learning mechanisms.

Many individual government departments and agencies have strategies and frameworks for reducing harm and preventable deaths in their areas of responsibility. One example is the Patient Safety Strategy updated by NHS England in July 2026. The purpose of this strategy is to continuously improve patient safety and evidence shows that is saving around 1,000 extra lives each year. The updated strategy can be found here: https://www.england.nhs.uk/patient-safety/the-nhs-patient-safety-strategy/.

In addition, the National Quality Board produced guidance in 2017 to help standardise and improve the way the NHS identifies, reports, reviews and investigates deaths to inform learning and improvement. Earlier this year, the newly revitalised National Quality Board commissioned a review of the national Learning from Deaths guidance to align with the introduction of the Medical Examiner system and new safety policy introduced via the NHS Patient Safety Strategy in 2019. The revision of the Learning from Deaths guidance will also incorporate a data strategy to support learning from deaths across the NHS in England. NHS England has met with Dr Georgia Richards and others working in the space of PFD analysis and the revised guidance will take this work into account. The Department for Health and Social Care tracks relevant PFD reports and ensures that relevant regulators and other bodies, are made aware of concerns, so that the relevant organisations can consider and act upon learning identified, including recurrent themes and risks.

More broadly, death certification, investigation, and registration system (including the coronial system and, through the reforms introduced by this Government in September 2024, the statutory Medical Examiner system) plays a vital role in establishing and recording universal and robust information about the circumstances of all deaths which take place in England and Wales. This information in turn contributes to work by ONS and other organisations to provide comprehensive and detailed mortality data for public benefit.

The Government recognises calls by the Infected Blood Inquiry and the Grenfell Inquiry that Parliament is the right body to undertake independent oversight of public inquiry recommendations and ensure that public authorities are held accountable for the actions they have committed to undertake. The Public Administration and Constitution Affairs Committee is currently looking at how Parliament can do this.

Ministers and officials regularly engage with a range of stakeholders on matters relating to the coronial system, including academic and research organisations. The Government recognises the contribution of the Preventable Deaths Tracker, led by Dr Georgia Richards of King’s College London, as well as work being undertaken by the Independent Advisory Panel on Deaths in Custody and by other academics, in supporting access to and analysis of published PFD reports, and ministerial meetings are considered and arranged in the usual way.