The Government recently published its response to the Grenfell Tower Inquiry Phase 2 Report.

An overview of the Government’s response can be found in our colleague Joanne Wright’s recent passle. Whilst, of course, the key takeaways from the response relate to fire and building safety, it also contains some interesting comments regarding the Prevention of Future Deaths Reports. 

What is a Prevention of Future Deaths (PFD) Report?

A PFD report, also known as a Regulation 28 report, is issued by a coroner, where they consider a significant risk has been identified through the inquest process and that if action is not taken in respect of that risk, further deaths will occur. The risk identified does not necessarily have to have directly caused or contributed to the deceased’s death.

These reports are sent to those that are in a position to address the identified risks (e.g., a private organisation or a Government department). The report must then be responded to within 56 days. The Chief Coroner maintains a public record of these reports, and any responses received. 

What did the Government say? 

Recommendation 25 proposed that the Government be legally required to maintain a publicly accessible record of recommendations it receives from select committees, coroners, and public inquiries, along with descriptions of the steps taken in response. The recommendation further proposed that if the Government decided not to accept a recommendation, it should record its reasons for doing so, with Parliament responsible for annual scrutiny of these actions.

In its response, the Government agreed in principle to this recommendation. On PFD Reports, the response states that more needs to be done to improve their accessibility and to ensure learnings from reports are disseminated as quickly and widely as possible and effectively monitored and evaluated. The Government states it is working with the Chief Coroner to make further improvements to the transparency and availability of reports and accountability for responses to them.  

Recent PFD reports issued by Coroners to Government departments have shown the potential for these to drive real change. For example, the PFD Reports relating to both Awaab Ishak and Natasha Ednan-Laperouse have led to significant changes in legislation and policy. 

On the other hand, the Chief Coroner’s recent list of PFD reports that have not been replied to shows they can simply be ignored, with coroners having no meaningful powers to enforce a response. Even where they are responded to, this is often considered in isolation, without someone looking at trends across different inquests up and down the country. 

Where a social housing or social care provider receives a PFD report, they are often held to account by their regulators in terms of implementing actions listed in their response – the same scrutiny appears to be lacking for the Government (but covered in the Inquiry’s recommendation). 

Whilst the Government's plans are welcomed, it feels more is needed to realise the full benefits of the PFD process in securing legislative and policy changes. 

The regulatory team at Anthony Collins are experts in guiding housing and health and social care clients through the inquest process. If you require representation for an inquest or assistance in responding to a request from the coroner, please get in touch.