Issue 2: Prevention of Future Death Reports in Health and Social Care: Do they make a difference?
After an inquest, a coroner has the legal power and duty to write a report if they believe that action should be taken to prevent future deaths. Under the Coroners (Investigations) Regulations 2013, the report, known as a Preventing Future Deaths report (PFD) or Regulation 28 report is sent to those in organisations local to the incident, or in regional or national positions, that are deemed able to take action to reduce this risk.
Between July 2013 and July 2017 an annual average of 430 PFDs were issued.i These reports are meant to be a powerful implement for positive change and crucial to enforcing improvements in patient safety. Their value is as important as ever as a report from the Nuffield Trustii showed that the UK has a poor amenable mortality index which looks to count the total number of deaths a country’s health system could have prevented, but failed to. If organisations did act on the recommendations in the PFD, there is no doubt that change would occur.
However, there is no mechanism to check that organisations do act on the PFD recommendations, and there are no apparent sanctions against organisations who do not respond. Neither the coroner, nor any national body, gathers information to show that since the PFD was issued, the risk of other deaths occurring in circumstances, similar or otherwise, at any organisation has reduced due to its issuance. So how effective are the reports?
In well led, safe organisations, a comprehensive and candid incident investigation process should mean that by the time a PFD is issued, the root causes of the events surrounding a patient’s unexpected or preventable death will have been determined, action plans developed and possibly implemented, and the risk of reoccurrence reduced. Organisations with robust and embedded governance processes in place and a proactive risk management culture would be able to monitor the implementation of the action plans, share any learning and then analyse the impact.
In other words the PFDs would be superfluous to requirements.
The aims of PFDs are the same as Serious Incident Investigations, CQC regulations, the Healthcare Safety Investigation Branch, and numerous other similar reports, initiatives and organisations are all the same: to improve patient safety. They all emphasise the same elements: thorough investigation, effective learning and regular review can lead to a reduction in patient harm, a reduction in complaints and a reduction in claims. This benefits everyone from patients through to the insurance market. However the same incidents keep occurring, the same root causes are cited and medical malpractice claims continue unabated. Since National Guidance on Learning from Deaths was published in March 2017, there is more structured approach to learning from deaths, so what novel value can a PFD report add now?
And what consistency is there in coroners issuing PFDs? There is a risk that subjectivity and discretion play a bigger part than should be appropriate for a PFD to be issued. Questions have been raised nationally about the variation in how a coroner reports a death influences a doctor’s chance of facing a gross negligence manslaughter charge.iii
It is interesting to note the number of PFD reports that do not appear to have been responded to. Or at least, have not been published. It’s striking that responses appear lacking from persons deemed able to take action which include the Secretary of State for Health and the Department of Health and Social Care.
Organisations do not need more affirmation that they have issues to address; they need help in improving risk management and governance processes.
Most organisations know action should be taken after a death has occurred, but many struggle with identifying the true causes where there’s been an incident or unexpected outcome and then finding a solution that will make a difference, so it appears that the role of the coroner in preventing future deaths is currently misplaced.
In the next blog we shall look at how the PFD system could be improved to create lasting and meaningful impact. Read it here
Caroline White
Healthcare Risk Control Director, CNA Hardy.
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i View all PFD reports at https://www.judiciary.gov.uk/related-offices-and-bodies/office-chief-coroner/pfd-reports/
ii https://www.nuffieldtrust.org.uk/files/2018-06/the-nhs-at-70-how-good-is-the-nhs.pdf
iii https://www.gponline.com/medical-manslaughter-prosecutions-postcode-lottery-warns-gmc-chief/article/1464117?bulletin=bulletins%2Fdailynews&utm_medium=EMAIL&utm_campaign=eNews%20Bulletin&utm_source=20180514&utm_content=GP%20Daily%20(127)::www_gponline_com_article_14641&email_hash