Following an inquest or investigation into a death, a coroner may issue a Regulation 28 Prevent Future Deaths (PFD) report to a person, organisation, local authority, government department or agency, where the coroner believes that action to address some of the identified concerns should be taken to prevent future deaths.

Receiving individuals or organisations have a statutory obligation to respond to the coroner’s PFD report and a deadline of 56 days to do so.

Extensions may be requested from the issuing coroner but may not always be granted.

Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 set out further information and the procedures that apply to reports and responses.

Issuing a PFD to NHS England

All PFDs for the attention of NHS England should be sent by email to england.coronersr28@nhs.net.

This ensures that they are picked up by a designated central team within NHS England’s Medical Directorate and logged appropriately. 

The National Medical Director responds to all PFDs addressed to NHS England. This function is designated to the National Medical Director by NHS England’s Chief Executive Officer.

NHS England PFD processes

When a PFD is sent to NHS England it is logged and coded under data categories for analysis. Categories include demographics, place of death and the main issue highlighted by the coroner.

This helps NHS England to identify new or emerging themes that may require further review or escalation.

The designated central team within the Medical Directorate will also commission the relevant policy and programme teams and experts within NHS England whose input is required to respond to a PFD.

Each of the 7 NHS regions also has designated PFD leads who will input into responses and PFD leads may engage with local systems and external stakeholders (such as integrated care boards (ICBs)) where appropriate.

Regulation 28 Working Group

The national Regulation 28 Working Group is an internal, multi-professional group comprising doctors, pharmacists, nurses and a range of other senior clinical, quality and programme/policy colleagues. There is also senior representation from each of the 7 NHS regions.

The Working Group is a sub-group of, and reports into, NHS England’s Executive Quality Group (EQG), part of NHS England’s internal quality governance structures.

The Working Group undertakes the following:

• meets to discuss all NHS England responses to PFDs and undertake due diligence
• shares insights with systems/ICBs
• tracks and monitors actions required, and commitments made within responses
• considers if additional actions need to be taken or escalations made
• undertakes thematic reviews into emerging themes or issues
• produces an annual report each year analysing PFDs received and reviewing responses and themes

How NHS England learns from deaths

Only a small proportion of inquests result in a PFD being issued by a coroner.

PFDs provide valuable insight and learning for the NHS and are considered alongside other information and intelligence received by NHS England that help improve services. These include:

• patient safety mechanisms
• medical examiner system
• clinical audit
• registries and data collections
• quality governance, oversight and reviews
• NHS England regulation and oversight
• external investigation and public inquiries
• external regulations

NHS England undertakes considerable work concerning wider safety processes and learning following an adverse outcome (for example, any poor treatment including but not limited to death).

Therefore, not all our safety and quality functions are listed above.

It should also be noted that NHS England does not have sight of all health-related PFDs issued to the NHS, for example where a PFD is issued to a hospital or GP practice.

Publication of PFDs sent to NHS England and responses

The Regulations 28 and 29, Coroners (Investigations) Regulations 2013 outlines the procedures that apply PFD reports and their responses.

It is the responsibility of the Chief Coroner to publish PFDs and their responses on the Courts and Tribunals Judiciary website alongside the publication and redaction policy.

NHS England treats all PFDs and the responses from our National Medical Director sensitively and does not publish our responses.

We advise that any media enquiries related to specific PFDs and their responses refer to the Courts and Tribunals Judiciary website.

Organisational mergers and NHS structures

In recent years, there have been several mergers between national NHS organisations to create one new NHS England.

NHS England now incorporates the functions of NHS Improvement, NHS Digital, NHSX, Health Education England and some former functions of Public Health England.

PFDs that encompass these functions should all now be sent to england.coronersr28@nhs.net for the attention of the National Medical Director.

The Health and Care Act 2022 also brought about significant structural change for commissioning.

ICBs took over the statutory responsibility for the commissioning of NHS services previously held by clinical commissioning groups, as well as taking on some of the direct commissioning functions previously held by NHS England.

Most of NHS England’s budget is allocated to ICBs, which commission most services for their population:

• primary care – GP services, optometry, dentistry, etc.
• secondary care, including urgent and emergency care
• delegated specialised services

Coroners should consider the commissioning landscape and functions when sending PFDs to NHS organisations.

For more information on commissioning responsibilities, please visit the Commissioning section of the NHS England website.

Publication reference: PRN01372