Lives at risk: The government’s inadequate management of coroners’ warnings about the NHS

Dr Minh Alexander | January 29, 2018 | Blog

Recent reports suggest up to 20 people in East Anglia may have died when ambulances arrived late to emergencies during a period of intense winter pressure

To avoid unnecessary future deaths we must ensure that coroners’ warnings about the NHS are heeded

The current revelations about deaths at the East of England Ambulance Service under winter pressures are profoundly shocking 1 2, but they are a progression of trends noted in coroners’ warnings about health services over the last several years.

Coroners have the task of certifying the cause of death in cases referred to them by doctors, or they may authorise certification by the referring doctor. The Chief Coroner has recently noted that that there is inadequate guidance for doctors on reporting deaths to coroners, which does ‘no more than encourage’ them to do so. 3 In 2016, 46% (241,211 of 524, 723) registered deaths were referred to coroners. 40,504 of these cases that were reported to coroners were deemed to need investigation and inquest. 3

Since 2013 coroners in England and Wales, after considering the cause of death, have been under a duty to issue reports on any action they think is needed to Prevent Future Deaths (PFDs). 4 PFDs are intended to prevent similar deaths and to ensure that all identified risks to life are acted upon, regardless of whether they caused the death that has been investigated. PFDs are only issued exceptionally. Between June 2016 and July 2017, 375 PFDs were issued. 3 In practice, the threshold for deciding that action is needed is high.

Parties, usually organisations, which receive a coroner’s PFD letter must respond in writing to the coroner, who in turn is also obliged to send all PFDs and the related responses to the Chief Coroner. The Chief Coroner has discretion to publish this material. 4 5

The system relies on reporting, but the Chief Coroner has confirmed that there is no sanction against respondents who default on their legal obligation to reply to PFDs. 6 There is also no apparent mechanism for dealing with unsatisfactory responses, and no power to compel action on coroners’ recommendations. The Chief Coroner has not indicated whether there are any arrangements in place to ensure that coroners submit their PFDs and the responses to his office. In his latest annual report, he states that he only encourages coroners to write and submit PFDs to him where appropriate:

The Chief Coroner encourages all coroners to write and submit PFD reports where appropriate.” 3

A review of PFDs published from July 2013 to July 2017 by the Chief Coroner reveals a total of 1,725 PFD reports. 987 of these (57.2 %) were reports sent to NHS organisations. 7 Recurring care failings emerged from the PFD data, many explicitly or implicitly linked to resource pressures.

A study of the reports raises important questions about the response of the organisations to which the warnings have been sent, and about learning and organisational memory. 7

A prominent finding was of deteriorating safety in ambulance services. It is clear that coroners have been increasingly concerned about ambulance response times and about underlying system pressures that have contributed to delays leading to deaths, such as hospitals which are themselves so overwhelmed that they struggle to accept patients from ambulance crews. 7 The ambulance crisis has been building in momentum for several years, and the current deaths at the East of England Ambulance Service are the culmination of unrelieved service pressure. When basic emergency care shows such strain, this should surely have led to government action.

Issues about the value of the PFD system itself became apparent. 62% of the PFDs published on the Chief Coroner’s website had no accompanying response. Since coroners began issuing PFDs, the Chief Coroner has published only a single trends analysis, for the period April-September 2013. 8

His office later advised that he published all the PFDs and responses he received. However, a review of the published data from a test sample of coroners’ offices, who all maintained that they had sent all their PFDs and responses to the Chief Coroner, revealed that 63% (216 of 342) of the responses to PFDs were absent from the Chief Coroner’s website. 9 The Chief Coroner has, however, committed in principle to full publication in future. 6

With regard to the Department of Health and Social Care (DHSC) and its arms’ length bodies the Care Quality Commission (CQC), NHS England, and NHS Improvement, enquiries have revealed defensive attitudes and a fragmented approach to the intelligence provided in PFDs. 9

All of them have refused to disclose responses to key PFDs. In doing so NHS England, the CQC and NHS Improvement relied on a technicality under the Freedom of Information Act (FOIA), which exempts court documents, whereas the Information Commissioner has advised that it is entirely within their discretion to publish. 10 The DHSC stated that it was the Chief Coroner’s job to publish and also referred to likely FOIA exemptions. 11 The documents which the DHSC et al. refused to release, which mostly remain unpublished by the Chief Coroner, relate to important matters such as national standards for ligature point management, deaths in custody, prison healthcare policy, safe staffing issues, and ambulance systems. 12

In 2014/15 the CQC undertook thematic analyses of PFDs by sector. It initially claimed that these documents were exempt from disclosure, but then released them with no explanation. NHS England started some analysis in 2017 and disclosed this data, although after an initial delay. 8

Although the arms’ length bodies have to varying degrees done little to track and analyse PFDs, they have at least made a start. 8 In sharp contrast to its arms’ lengths bodies the DHSC maintains that there is little use in analysing PFD data on the grounds that it is insufficiently standardised, and could lead to ‘misleading conclusions’. 12 If the government genuinely held this concern, it should, evidently, have taken action to ensure that the data was fit for analysis. But as noted above, no more than ‘encouragement’ has been applied in the management of PFDs.

The severity of the failures may be illustrated by reference to a sub-analysis of PFDs about the deaths of older people in NHS hospitals. 14 For example, the death of Susanna Geraty, a fit 75 year-old who died because she was not given adequate fluids:


From the Surrey coroner’s warning about the death of Susanna Geraty




During the course of the inquest the evidence revealed matters giving rise for concern. In my opinion there is a risk that future death will occur unless action is taken. In the circumstances it is my statutory duty to report to you.


The MATTERS OF CONCERN are as follows:


1. Failure to assess, monitor and record post operative fluid balance.

2. Inadequate nursing records

3. Inadequate fluid balance charts

4. Failure to respond to legitimate concerns raised by the family

5. Failure to recognise an acutely unwell patient

6. Failure of the SI report to consider or acknowledge dehydration as a possible cause of acute renal failure


Coroners’ letters or PFDs are meant to prevent unnecessary deaths.

Proper government tracking and analysis of PFDs would be likely to reveal areas of unmet need and policy deficiencies. The failure of government bodies to properly heed warnings from their own alarm system constitutes a serious failure by the state to protect people’s lives. Parliamentary oversight appears needed to overcome the DHSC’s reluctance to account for how it handles coroners’ letters.

Editorial note: This blog is drawn from a longer report by Dr Alexander that looks at the data and history of PFDs in more detail. This can be found here.

1 Whistleblower claims 20 people died where ambulances were late, Richard Porritt, Norwich Evening News, 17 January 2018

2 East of England Ambulance patient might have ‘frozen’ to death, Julian Sturdy and Laurence Cawley, BBC East 19 January 2018

3 Chief Coroner’s annual report 2016/17

Click to access chief-coroner-report-2017-web.pdf

4 Justice and Coroners Act 2009 Schedule 5 Powers of Coroners Action to prevent other deaths

7 (1) Where— (a) a senior coroner has been conducting an investigation under this Part into a person’s death, (b) anything revealed by the 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 (c) in the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances, the coroner must report the matter to a person who the coroner believes may have power to take such action. (2) A person to whom a senior coroner makes a report under this paragraph must give the senior coroner a written response to it. (3) A copy of a report under this paragraph, and of the response to it, must be sent to the Chief Coroner.”

The Coroners (Investigations) Regulations 2013


  1. (5) On receipt of a report the Chief Coroner may—

(a)publish a copy of the report, or a summary of it, in such manner as the Chief Coroner thinks fit; and

(b)send a copy of the report to any person who the Chief Coroner believes may find it useful or of interest.”

5 Chief Coroner’s Guidance Note No 5, on Reports to Prevent Future Deaths, 16 July 2013

6 Correspondence with Chief Coroner’s office

7 Four years of published coroners’ Section 28 reports in England and Wales, 24 August 2017

8 Summary of reports to prevent future deaths (formerly Rule 43 reports), Chief Coroner December 2013

Click to access april-2013-to-september-2013-summaryreportofpfdreportsapr-sep2013-10th.pdf

9 Safe in their hands? Government’s response to coroners’ warnings about the NHS, 19 January 2018

10 NHS England, CQC and NHS Improvement all relied on this past ICO decision that responses to coroners’ Section 28 reports are court documents and therefore exempt under Section 32 of the FOIA: However, the ICO has confirmed to me that there is nothing to stop these bodies from voluntarily disclosing their responses to coroners if they choose to do so:

An organisation can choose to proactively publish information even if that information is exempt from disclosure under the Freedom of Information Act, or if the organisation is not subject to the Act.”

ICO Group Manager of FOI Appeals and Complaints Department 6 December 2017

11 Letter from the Department of Health 10 October 2017

“It is therefore for the Chief Coroner to determine the appropriate format for publication of this material and the Department would not wish to undermine this process.”

12 To give an example, NHS Improvement has refused to disclose its response to this coroner’s request for more rigorous national standards on ligature risks. East Riding and Kingston upon Hull coroner’s warning about the death of Helen Millard under the care of Humber NHS Foundation Trust 6 October 2016:

12 Letter from the Department of Health 10 October 2017:

I would point out that there are a number of variable factors to bear in mind when attempting to draw conclusions from the material published online. For example, it is a matter for individual coroners to determine if, and when, a report on action to prevent future deaths should be made, and to whom. It may be the case that some coroners utilise this tool more than others, meaning and to whom. It may be the case that some coroners utilise this tool more than others, meaning that discerning any notable themes or patterns, such as commonly featured NHS trusts, can lead to misleading conclusions.”

14 CQC, coroners’ warning and the neglect of older people in hospitals, 2 October 2017

Support Our Work

CHPI is the only truly independent health think-tank dedicated to the founding principles of the NHS. To continue our work keeping the public interest at the centre of health and social care policy, we need your help.

Please support CHPI so we can continue to impact the health policy debate.

About the author

Avatar photo

Dr Minh Alexander

Dr Minh Alexander is a former consultant psychiatrist based in Cambridgeshire.See all posts by Dr Minh Alexander