More Than a Paper Exercise: Enhancing the Impact of Prevention of Future Death Reports

All should ensure that their approach to the PFD process is open, non-defensive and that the public interest in preventing future deaths is prioritised over reputational considerations at every stage. For example, lawyers should be specifically instructed not to take an adversarial approach to the making of a PFD report, and instead to neutrally present the evidence in order to assist the coroner.

All should ensure that they approach the PFD process with full candour and proactively provide all relevant information at the earliest appropriate stage.

The Ministry of Justice (MoJ) should adequately resource the Chief Coroner's Office to produce a yearly review of PFD reports for custody deaths. This should aim to identify themes and trends, and report on the timeliness and quality of responses, as part of the Chief Coroner's role under existing guidance.

The MoJ should provide dedicated funding to the Chief Coroner's Office to enable it to centrally record the conclusions of inquest juries, even where no PFD report is issued, and publish them online for easy referral in the same way that PFD reports are currently published.

The Department of Health and Social Care (DHSC) should give serious consideration to the creation of an independent body for investigating deaths of those formally or informally detained in mental health settings. This would remove the anomaly between the investigation of such deaths and those of persons in other detention settings and ensure that coroners consistently have the benefit of high quality evidence regarding the circumstances of such deaths for the purposes of the inquest.

Recipients of PFD reports relating to deaths in custody should hold a "post-inquest learning review" meeting following the conclusion of an inquest, attended by the key persons who participated in the inquest. This will help to ensure both an efficient and fully informed response to PFD reports and the formulation of an appropriate action plan to take forward necessary learning.

Recipients of PFD reports should ensure that their responses are timely, high quality, case-specific, and fully informed by the inquest evidence and findings. Where the response relays that action will be taken, actions should be identified in precise terms and with precise timelines. Where no action is to be taken, a clear, detailed and respectfully worded explanation should be provided to enable the coroner, family, and wider public to understand the basis for the decision. Recipients should ensure that their responses recognise and reflect the significance of PFD reports to bereaved families, with consideration given to how families can be kept informed and where appropriate consulted on the action plan.

All should ensure PFD reports are shared 'horizontally' with relevant equivalents across the country – for example, other police forces, prisons, and mental health trusts – particularly where there may be scope for national learning, to ensure opportunities to make change across different custody areas are not missed.

Leaders of local custody bodies, such as prison governors, should consider adopting the approach of Milton Keynes Together Safeguarding Partnership and hold periodic meetings of representatives from all custodial settings to review relevant PFD reports, with participation, where appropriate, of local coroners.

Government should consider what enhanced role independent bodies might play in auditing, following up on, and reporting on PFD reports, and this could include establishing a new body for this purpose. More effective oversight of the sharing, use, and implementation of matters of concern in PFD reports is needed.

The Chief Coroner should consider supplementing his guidance on PFD reports to further address when it may be appropriate, in compliance with the statutory requirements, to make interim PFD reports and the importance of doing so, in particular where a coroner is of the opinion that there is an urgent need for action to prevent future deaths.

The Chief Coroner should consider supplementing his guidance to advise coroners on the importance of ensuring relevant evidence is provided at a sufficiently early stage, in particular where coroners consider there may be a need for urgent action. The guidance should remind coroners that previous PFD reports and evidence of 'near-miss' incidents may be relevant and important.

The Chief Coroner's Office should review and consider expanding the list of organisations which should receive PFD reports on deaths in state custody (found at paragraphs 56 and 57 of the guidance on PFD reports) to ensure more comprehensive coverage of relevant bodies, organisations, and departments. This should be circulated to all coroners and used in training on PFD reports. The IAPDC could assist with ensuring this list is up to date and comprehensive.

The Chief Coroner's Office should ensure that its online database of PFD reports is fully searchable by thematic areas and location, and that deaths in detention (particularly under the Mental Health Act 1983 (MHA) are readily identifiable. Consideration should be given to tagging reports according to the deceased's protected characteristics to help better identify and understand issues of disproportionality.

The Ministerial Board on Deaths in Custody secretariat should send PFD reports on deaths in custody to the House of Commons Justice, Health, and Home Affairs Select Committees, which should consider taking evidence and reporting on significant themes.

All organisations which scrutinise places of detention should make explicit use of PFD reports to inform their investigations, inspections, and thematic reports and bulletins, including monitoring and reporting on progress made against responses to PFD reports by services and agencies. They should work with the Chief Coroner to agree protocols to work together and share learning.

The Ministerial Board on Deaths in Custody (MBDC) secretariat should continue to review and distribute PFD reports relating to death in custody to MBDC members for the purpose of sharing learning, and consider involving all relevant agencies and partners who would benefit from additional learning across all places of state detention. Issues of significant wider concern arising from recent PFD reports should be discussed at MBDC meetings.

The Judicial College should work with the Chief Coroner to deliver mandatory training to coroners on the purpose, process, publication, and distribution of PFD reports, as well as the role of independent scrutiny bodies, incorporating the perspective of bereaved families.