Warnings from coroners must have the force of law | Letters
We wholeheartedly agree that Prevention of Future Deaths (PFD) reports issued by coroners should have legal force to save lives (The Guardian view on the role of the coroner: If deaths can be prevented, they should do that, October 8). We suggested this last December to Maria Caulfield, then Parliamentary Under Secretary of State at the Department of Health and Social Services: she listened kindly but did not answer.
Each inquest examines an individual tragedy and is moving for relatives: describing the life and death of your child in court is harrowing. Fortunately, the coroner who investigated the death of our daughter Juliet Saunders was both thorough and kind: he described Juliet as “student” on her death certificate, without taking into account her learning difficulties. He found that neglect had contributed to her death and issued a PFD because he could not see that the trust in question had taken preventive measures.
The investigation revealed information the trust had concealed, systemic failings and details of poor care from doctors. Since the trust has not accepted full responsibility for almost another year (in 2022), it seems impossible to say whether improvements would have been made without the PFD. We were therefore shocked when we found that there was no enforcement. An inspector from the Care Quality Commission told us that the measures were in place, but they were not mentioned in his inspection report. We have no way of knowing whether the guarantees will be honored.
Only 25% of deaths among people with learning disabilities are referred to a coroner (36% for the general population), but the NHS programme intended to reduce preventable 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) states: “Very often valuable material becomes locked up in a report and… is in danger of being lost.” Surely this also applies to PFDs?
Christine and Francis Saunders
Romford, Essex
We believe the Guardian is right to highlight the impact of the lack of coordinated and adequate action that could be so helpful following a PFD announcement.
This has echoes of another area – that of deaths of adults with acquired brain injury (ABI), where there is a ‘protecting adults review’ (SAR). The publication of the report into the death of “Tom” by Somerset Protecting Adult Council lists significant failures by numerous health and social care services to understand how Tom’s brain injury has affected his functioning over decades, resulting in his likely preventable suicide. This document identifies clear shortcomings and yet these words are almost exactly echoed in other SAR reports from across the UK; the case of “James” in Brighton is another good example.
As part of a process to update academic work, we have identified 24 so far SAR reports in individuals with ABI where the same pattern is observed. How many of the millions of people in Britain affected by brain injury live impoverished lives with their potential unfulfilled, all because of the lack of adequate, community-based, specialist health and social care services; And how many more people will live and die in misery before this becomes a reality?
Dr. Mark Holloway
Coroner’s expert in the case of “James”
Dr. Alyson Norman
Associate Professor of Psychology, University of Plymouth, and brother of “Tom”