Issue 3: Prevention of Future Death Reports in Health and Social Care: how the system could be improved to create lasting and meaningful impact.
In the previous blog of this series it was proposed that Prevention of Future Death Reports (PFDs) were not as effective as they perhaps could be. There is no doubt that the intention of PFDs is to improve patient safety however there are obvious gaps in the process. How can the current system be improved to create lasting and meaningful impact whilst dovetailing with, rather than duplicating, the work of other agencies concerned with health and social care safety?
A review of the available data suggests that PFDs have lost the authority that they used to have: In the Gosport Inquiry into the unjustified prescription and administration of medications it is documented how keen the organisation was to avoid a Rule 43 report (the predecessor to PFDs) because to receive one had such a powerful impact on staff and organisational reputation. Government records show that the majority of organisations responded to Rule 43 reports, but now only 38% of responses to PFDs are published.i Whether this is due to decreasing response rates or the Chief Coroner’s choice not to publish is unknown but in the era of transparency and candour it seems a curious decision to withhold such information without explanation.
To improve the authority of PFDs, a more visible arrangement for responses, which promotes accountability, must be found. Healthcare organisations have many competing priorities and will undoubtedly focus on requirements where sanctions for non-compliance exist. There is no apparent sanction for failing to respond to a PFD. Finding out if organisations have responded to a PFD is a cumbersome task; perhaps if the website of the Office of the Chief Coroner simply presented the information in a more obvious and searchable format, it could help make organisations more visibly accountable for their role in the PFD process.
Assurance would increase accountability.
Where a response to a PFD exists it will include an action plan meant to demonstrate how the PFD recommendations are going to be met, however once the response has been submitted, where is the assurance process that ensures that the proposed actions are executed? Inquests take time and considerable expertise so it seems remiss not to complete the exercise and insist on obtaining verifiable evidence that the action plan was more than a document of platitudes. Again the website could then simply indicate any failure to do so, which could be followed up by a number of organisations that ought to be interested e.g. the Care Quality Commission, NHS England, Public Health England or any number of Clinical Commissioning Groups.
Coroners provide a valuable service to increasing patient safety by issuing PFDs but it is only one part of their extremely busy roles. There is no national service, coroners are funded by local authorities and as the Chief Coroner pointed out in his 2016/17 annual reportii, there is an issue with standardisation and consistency. Having a national service would mean that there could be a more uniform approach to PFDs; it may also raise their profile within the coroner service. In the Chief Coroner’s 75 page report, PFDs were only given a small mention and the only analysis of the 375 PFDs reported that year was of 10 PFDs relating to prisons. Not analysing all of the PFDs reported annually for themes e.g. geographical, economic and clinical, and publishing it nationally, seems like a wasted opportunity and does nothing to emphasise or realise their value. The Chief Coroner has reported on the lack of resource in the coronial service but by simply publishing more information in a format that lends it to better critique, these themes could be ascertained by others and used to ultimately improve patient safety.
It is clear that a lot of work, time, skill and resource are involved in the issuing of PFDs so not seemingly closing the cycle with audit is in danger of further rendering the process impotent. Insisting that an audit is carried out to show whether the PFD has made any difference in the organisation it was issued is surely just common sense.
Improving systems that are under resourced is obviously hard. However small changes could be made to the presentation and searchability of information on the website and more governance requirements and accountability could be placed onto healthcare organisations. This in turn could make a large, positive change on the impact of Preventing Future Deaths reports to do just that, prevent future deaths.
Caroline White
Healthcare Risk Control Director, CNA Hardy.
To find out more about our Risk and Governance Services please email
[email protected]
i https://minhalexander.files.wordpress.com/2017/08/four-years-of-published-coroners_-section-28-reports-to-prevent-future-deaths-in-england-and-wales.pdf
ii https://www.judiciary.uk/wp-content/uploads/2017/11/chief-coroner-report-2017-web.pdf