The family of Maeve Boothby O’Neill, who died aged 27 after suffering from myalgic encephalomyelitis (ME) for many years, is not the first to reach the end of an inquest only to be faced by uncertainty regarding its results. The coroner issued a prevention of future deaths notice (PFD) addressed to Wes Streeting and five health organisations, including NHS England. This criticised the lack of specialist care and training for doctors, and raised concerns about clinical guidelines and nutrition. But while there is a legal obligation on any body in receipt of such a notice to respond within 56 days, there is no requirement on them to take any action at all.
Prevention of future deaths notices are a crucial part of the inquest system. They exist so that as well as investigating the causes of violent or unexplained deaths, coroners can seek to ensure that their findings are learned from. Given that these documents deal with risks to life, and are the outcome of a legal process, they obviously ought to be heeded.
Unfortunately, the present system does nothing to ensure that this happens. PFDs are issued in only a tiny proportion of the 35,000 inquests held each year in England and Wales. Last year, there were 550. This total has significantly increased over the past decade. So has the proportion citing an NHS resource issue as a factor. Last year, this rose to one in five of the total, from one in nine in the two years before the Covid pandemic. Families, who generally meet resistance from health trusts and other organisations when calling for notices to be issued, may derive a degree of satisfaction when a coroner agrees with them. But it is not unusual for a letter of acknowledgment from the relevant body (which could be a business or a public authority) to be followed by silence.
In the Grenfell inquiry report, the failure to take seriously the coroner’s notice issued after the Lakanal house fire was singled out as a missed opportunity to address the risks of plastic cladding. More recent coroner’s notices have highlighted understaffing as leading to unacceptable levels of risk in prisons, and failures by mental health services.
In April, a coroner issued a PFD calling for a review of all indeterminate sentences after the inquest into the death of Scott Rider, who took his own life in his cell. But the lack of any systematic monitoring of institutions’ responses to notices has led campaigners and the charity Inquest to demand the creation of a new oversight mechanism. This would keep track of inquest and inquiry recommendations and ensure that they are not allowed to sink into bottom drawers.
The uncertain status of PFDs is not the only problem in the inquest system. Around 2,000 families have been waiting at least two years for an inquest, which is meant to take place within six months. Last year, the outgoing chair of parliament’s justice committee, Sir Robert Neill KC, wrote to the government highlighting problems including chronic underfunding. But the unsatisfactory situation regarding PFDs must be addressed. They should be recognised as opportunities that are too valuable to miss. The existing arrangements are a disservice to everyone involved in the inquest process, above all the families who hope to prevent others from experiencing similar losses to theirs. The public stands to benefit if risks are identified, errors are corrected and cultures and practices are changed.
