We wholeheartedly agree that prevention of future deaths (PFD) reports issued by coroners should have legal force in order to save lives (The Guardian view on the coroner’s role: if deaths can be prevented, they should be, 8 October). We proposed this last December to Maria Caulfield, then Department of Health and Social Care parliamentary under-secretary of state: she listened kindly but made no response.
Each inquest investigates an individual tragedy and is harrowing for bereaved relatives: describing your child’s life and death in court is distressing. Fortunately, the coroner investigating the death of our daughter Juliet Saunders was both thorough and kind: he described Juliet as “student” on her death certificate, disregarding her learning disabilities. He found that neglect had contributed to her death and issued a PFD as he could not see that the trust concerned had taken preventive action.
The inquest elicited information that the trust had concealed, systemic failings and details of poor care from clinicians. As the trust did not admit full responsibility for almost another year (in 2022), it seems impossible to say whether any improvements would have been implemented without the PFD. We were therefore dismayed to find that there was no enforcement. A Care Quality Commission inspector told us the measures were present, but they received no mention in his inspection report. We cannot know if assurances are kept.
Only 25% of deaths of people with learning disabilities are referred to a coroner (36% for the general population), yet the NHS programme intended to reduce avoidable deaths does not record PFDs, even in cases of neglect. At our request, it was included in Juliet’s review. The 2013 report of the confidential inquiry into the premature deaths of people with learning disabilities (Cipold) said: “Very often valuable material gets locked in a report and … is in danger of getting lost.” Surely this is equally true of PFDs?
Christine and Francis Saunders
Romford, Essex
We believe that the Guardian is correct to highlight the impact of the lack of co-ordinated and adequate action that could be so beneficial following a PFD notice.
This has echoes of another arena – that of the deaths of adults with acquired brain injury (ABI) where there has been a safeguarding adults review (SAR). The publication of the report into the death of “Tom” by Somerset safeguarding adults board?lists significant failings by numerous health and social care services to grasp how Tom’s brain injury impacted his functioning over decades, resulting in his likely preventable suicide. This document identifies clear failings and yet these words are mirrored almost precisely in other SAR reports from around the UK; the case of “James” in Brighton is another prime example.
As part of a process of updating some academic work, we have so far identified 24 SAR reports into individuals with ABI where the same pattern is witnessed. How many of the millions of people in the UK affected by brain injury are leading impoverished lives with their potential unfulfilled, all for the want of adequate community-based specialist health and social care services; and how many more will live and die in misery before this becomes a reality?
Dr Mark Holloway
Coroner’s expert in case of “James”
Dr Alyson Norman
Associate professor in psychology, University of Plymouth, and brother of “Tom”
