26/09/2025
Regulation 28 reports or Prevention of Future Death reports (“PFD’s”) are issued by a Coroner when they have concerns that there is a risk of death to a member of the public.
It would be wrong, however, to assume that they are a concern only for public bodies. In fact, the direct impact of PFD’s, and indeed the indirect commercial and regulatory implications, can be far more elevated for Independent Health and Care providers.
Bevan Brittan have noted an increase in PFD’s in relation to the independent care sector. For example, throughout 2024, there were 34 reports issued concerning the care home industry alone. As of mid - September 2025 there have already been 33. This is in the context of a total of 569 PFD’s issued in 2023 and 713 PFD’s issued nationally in 2024 – a rise in PFD’s of over 25%.
Despite the often-repeated reassurance that PFD’s are not “badges of dishonour”, receipt of such a report can nonetheless have significant ramifications on an independent health and care organisation, not least the time and financial resources required to properly respond to the report, but more pertinently the commercial ramifications in terms of sale, financing and insurance.
The potential impact of most concern is the severe reputational damage that can occur which then can result in commercial implications. This can especially be the case when the press takes an interest, as they often do when a PFD is issued and often in a far more rigorous and sensationalist manner for independent health and care providers in comparison to their NHS counterparts. One only needs to google “care home” and “prevention of future deaths” to immediately return the following recent results (all from BBC News) -
“A coroner says a possible "culture of cover up" at a care facility could lead to further deaths” – 21 May 2025
“Woman's care home death preventable – coroner” – 2 July 2025
“Care home told to act after resident's death” – 4 July 2025
Such headlines are of course unwelcome in an industry already struggling with funding and recruitment.
It may also come as an unwelcome surprise to learn that PFD’s are published on the Courts and Tribunals Judiciary webpage. Although individuals are not named within these reports, the organisations involved are. CEO’s and Board members are frequently approached off the back of the publication and regulatory antennae can then be triggered, along with investigative journalism such as Panorama-type reporting. This ‘noise’ surrounding a PFD can significantly impact on independent health and care providers in particular.
A review of the published PFD reports features a surprising number associated with poor internal investigations. Of the aforementioned 33 reports issued to care home operators, the Coroner raised poor investigations on 15 occasions. Let us therefore look at those to see if any patterns can be recognised.
Alarmingly, 4 of those PFD’s were issued simply because there had been no internal investigation whatsoever. On one notable report the Coroner commented that there has “been little reflection of the events” and ultimately concluded there was “no mechanism for lessons to be learned from deaths which occur during or following admission to the Nursing Home.”
If you’re going into an inquest without having done an investigation, be prepared for a possible PFD!
But you’ve done an internal investigation, so you’ll definitely be fine right? Think again!
In 5 of the reports Coroner’s were critical of the adequacy of investigations which had been conducted to the extent that they felt there was still a risk of future deaths.
Indeed, in one report the Coroner’s concern was so marked that they feared there was actually a culture of cover up with a flawed investigation pushing blame onto an innocent individual and thereby avoiding highlighting systemic failures and learning.
Whilst you will, no doubt, not be making that mistake, other lessons flow from the concerns raised by Coroners in the PFD’s, that might be more applicable. These include ensuring that -
- the correct people carry out the investigation;
- staff have training in how to conduct an investigation;
- policies and guidance exist with regards to investigations; and
- all key documents are considered thoroughly.
The importance of the last of those arises from a PFD in which the Coroner noted that a care record had been filled out to say the deceased had received sustenance. The slight issue with that was that entry was timed two hours after the death and so was undoubtedly a false record. One anticipates that the fact that this had not been picked up on by the investigator rather dented the Coroner’s confidence in the overall robustness of the investigation.
Okay, so actually your investigation has been pretty solid so you won’t be getting a PFD right? Sorry not necessarily!
In the remaining 6 PFD’s the Coroners cited a lack of evidence for change as a reason that they still had concerns of a risk of future deaths. In other words organisations may well have conducted thorough investigations and identified issues but they had not taken the final step of proving the implementation of change. They had fallen therefore at the final coronial hurdle. Somewhat frustrating no doubt for those organisations!
Previously in such circumstances Coroner’s may have been satisfied with a promise to update them as to progress, or indeed simply by the existence of a future dated action plan. Of course technically a Coroner’s jurisdiction stops once the inquest is concluded and ‘updates’ as to actions to be taken by organisations can not be compelled. This is possibly why we have seen an increased appetite to issue PFD’s now and ask questions later.
Overall what then can we conclude from this?
Firstly it seems evident that PFD reports are being issued with more frequency in the independent health and care sector.
Secondly there is a growing need to conduct thorough and effective investigations after a death.
Thirdly this is not the end of the process. It is also vital to ensure that the outcomes of your investigation and crucially changes adopted as a consequence, are properly advanced and are demonstrable to a Coroner. Your organisation’s relationship with the Coroner and the jurisdiction will also necessarily carry some weight in this regard.
A PFD on the face of it should be entirely avoidable if a thorough internal investigation has occurred. That of course is not always the case and some obscure issues may arise during an inquest that could not have been considered. But 99% of the time a PFD should be avoidable. Furthermore, as learning organisations, a thorough internal investigation and implementation of recommendations and actions will by necessity drive quality, address any cultural issues and minimise the risk of future deaths. All of which has a positive impact on organisations commercially.
Our Independent Health Care team are a specialist team that understands the sector and the commercial implications of negative outcomes at inquest and beyond. We are a team of sector dedicated lawyers who can fully assist and support your organisation with proper preparation and representation at inquest, associated regulatory concerns and media management.
If you would like to speak to our team, please get in touch with:
amanda.wright-kluger@bevanbrittan.com
07586 691430
