Inquest Team E-Bulletin – August 2019

Reports to Prevent Future Deaths: Case Update Summer 2019

Three cases illuminate the breadth of coronial powers to issue reports to prevent future deaths (‘PFD report’) under Coroners and Justice Act 2009, Schedule 5 paragraph 7(1), and the difficulty in challenging them.

1. In the Grenfell Tower inquests, a report was issued by the Senior Coroner for Inner West London, Dr Fiona Wilcox, in September 2018. The report does not focus on fire safety, which is within the remit of the ongoing public inquiry. The report instead focussed on the need for health screening and psychological support for survivors, fire officers and first responders. It was noted that NHS psychological support was only funded until March 2019, and that there was no physical-health screening programme to monitor the effect of inhalation of smoke and dust with toxic fumes and possible asbestos exposure. The Coroner directed the report to NHS England. The requirement to make a PFD Report is triggered where a senior coroner has been holding an investigation and ‘anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and in the Coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances’. 

   This case is a strong reminder that the subject matter of the PFD does not need to be linked to the causation of death in any way.

2. Inquest into the death of Geoff Gray, 20 June 2019 (Record of Inquest here and findings of fact here). In this inquest into the death of a young man at Deepcut Barracks, the Coroner took the unusual, and probably unprecedented, step of issuing a PFD report directed at the Chief Coroner. The inquest revealed that an assumption had been made that Mr Gray’s death was a suicide, and a cursory post-mortem examination was performed. It was found that other deaths at Deepcut had been investigated in a similarly cursory fashion. The post-mortem was not documented by photograph or body map, and there were no attempts to match the entry and exit wounds with clothing. The Coroner’s concern was that homicides would not be detected and vital evidence lost unless the quality of investigations was improved dramatically. The PFD report was directed at the Chief Coroner and Royal College of Pathologists, and suggested that amendments to guidance might be needed to ensure that full post-mortems were carried out even when initial signs pointed to self-infliction.

3. R (Dr Siddiqi and Dr Paeprer-Rohricht) v Assistant Coroner for East London. Admin Court CO/2892/2017 decision 28 September 2017.

   This older case is a reminder that PFDs cannot be challenged through the court system. The claimants, both GPs, sought to challenge the Assistant Coroner’s decision to issue a PFD report after an inquest into a patient’s death. The Coroner was concerned about how the surgery dealt with patients’ A&E discharge summaries. This was not causative of the death, but was, in the Coroner’s view, a situation which created a risk of other deaths. The judicial review failed: the remedy which was being sought, to make the Coroner withdraw the PFD report, was not a lawful remedy. A coroner has no power to withdraw a report, once issued. The only remedy is to issue a response, and press the Chief Coroner to make the response public.

Kate Brunner QC