When a coroner identifies concerns during an inquest that could place others at risk in the future, they can issue a Prevention of Future Deaths (PFD) Report. These reports are intended to highlight safety concerns, encourage learning and prompt organisations to take action to help prevent similar deaths from occurring again.
For NHS trusts and healthcare providers, PFD Reports provide an important opportunity to review systems, procedures and patient safety practices. By examining the concerns raised by coroners, organisations can identify areas where improvements may be needed and consider what action should be taken to reduce the risk of future harm.
While every case is unique, a review of recent Prevention of Future Deaths Reports relating to Hull, Northern Lincolnshire and York & Scarborough highlights several recurring patient safety concerns, offering valuable insight into how healthcare providers can reduce risks and improve patient outcomes.
What is a Prevention of Future Deaths Report?
A Prevention of Future Deaths Report is a formal report issued by a coroner when evidence heard during an inquest suggests there is a risk that future deaths could occur unless action is taken.
The report is sent to the organisation, body or individual best placed to address the concern. This may include NHS trusts, healthcare providers, government departments, regulators or other public bodies. Recipients are generally required to respond within 56 days, outlining what action has been taken, or is proposed, in response to the concerns identified.
PFD Reports are not intended to apportion blame. Their purpose is to identify lessons that can be learned and encourage improvements that may enhance public safety.
The National Picture
The Preventable Deaths Tracker, developed to monitor and analyse PFD Reports, highlights the scale of these investigations across England and Wales.
According to the tracker:
- More than 6,800 Prevention of Future Deaths Reports have been published since 2013.
- The reports relate to more than 6,300 deaths.
- Approximately 64.4% of reports have a complete published response.
- Around 22% have no published response recorded.
These figures demonstrate both the volume of concerns being raised by coroners and the importance of ensuring organisations engage meaningfully with the process.
While national statistics provide an overview of the scale of Prevention of Future Deaths Reports, local reports offer valuable insight into the patient safety issues affecting healthcare services across Hull, Northern Lincolnshire and York & Scarborough.
Overall Local Themes
Across Hull, Northern Lincolnshire and York & Scarborough, the reports consistently highlight concerns regarding:
- Delays in recognising deterioration and serious illness
- Safe discharge planning and community follow-up
- Falls prevention and care of frail patients
- Communication and record keeping
- Patient identification procedures
- Staffing and wider system pressures
- Learning from incidents and implementing improvements
Recent reports from the region have highlighted concerns including delayed diagnosis, failures to recognise deteriorating patients, discharge planning and follow-up care, inpatient falls, patient identification errors and wider service pressures. Coroners have also raised concerns regarding communication between services, record keeping and the importance of learning from incidents to reduce the risk of future harm.
The reports examined relate to healthcare services across Hull University Teaching Hospitals NHS Trust, Northern Lincolnshire and Goole NHS Foundation Trust and York and Scarborough Teaching Hospitals NHS Foundation Trust, providing insight into issues affecting patients across the region.
Delays in Recognising Deteriorating Patients
One of the most common themes identified in local PFD reports is the importance of recognising deteriorating patients and responding appropriately.
Reports involving both Hull and York & Scarborough have raised concerns about delays in diagnosis, failures to recognise serious illness and missed opportunities to escalate concerns or seek specialist input. In some cases, coroners identified concerns regarding the interpretation of test results, the management of complex medical conditions and delays in treatment for patients whose condition was worsening.
These reports highlight the importance of timely assessment, appropriate escalation and effective communication between healthcare teams.
Safe Discharge and Follow-Up Care
Another recurring theme relates to the transition from hospital to community care.
In Hull-related reports, coroners raised concerns regarding discharge planning, communication with community services and the arrangements put in place following discharge from hospital. Concerns included incomplete discharge information, missed referrals and uncertainty regarding responsibility for ongoing community care.
These reports demonstrate how important effective discharge planning can be in helping patients receive the ongoing support and monitoring they require once they leave hospital.
Falls Prevention and the Care of Frail Patients
Falls prevention also features prominently in local PFD reports.
Several reports involved elderly or vulnerable patients who suffered falls either in hospital or shortly after receiving care. Coroners raised concerns regarding staffing levels, patient supervision and ensuring appropriate mobility aids were available when patients moved between wards.
As hospitals continue to care for increasing numbers of elderly and frail patients, preventing falls remains an important patient safety priority.
Communication, Record Keeping and Patient Identification
Several local reports highlight the crucial role that communication and record keeping play in patient safety.
Concerns have included issues with discharge documentation, delays in communicating important findings, record-keeping deficiencies and failures to follow patient identification procedures before investigations or treatment. In one case, a patient underwent a scan in error after being mistaken for another individual with the same first name, prompting concerns regarding identification checks and follow-up processes.
These reports demonstrate how even relatively simple administrative and communication errors can have significant consequences for patient care.
Where avoidable mistakes result in harm, patients may benefit from obtaining advice from specialist medical negligence solicitors.
NHS Staffing Pressures and Patient Safety Challenges
Some local reports also point towards wider system pressures that can affect patient safety.
Coroners have identified concerns relating to staffing shortages, continuity of care, winter pressures, ambulance response delays and ambulance handover delays at hospital emergency departments. Concerns were also raised regarding the impact that these pressures may have on patient supervision, falls prevention and timely treatment.
While healthcare professionals work hard to deliver safe and effective care, PFD reports demonstrate the importance of ensuring systems and resources can adequately support frontline services.
Infrastructure and Equipment Safety
Local Prevention of Future Deaths reports have also highlighted the importance of hospital infrastructure and equipment safety. In one Northern Lincolnshire case, a coroner raised concerns after an unexpected loss of electrical power during a cardiac procedure affected the ability to provide emergency treatment. The report highlighted how hospital systems, equipment and emergency procedures can play an important role in patient safety alongside clinical care.
Learning from Mistakes
Perhaps the most important theme running through many Prevention of Future Deaths Reports is the need to learn from incidents when they occur.
Several coroners expressed concerns not only about the events leading to a death, but also about delays in investigating what happened, identifying lessons and ensuring learning was shared. Effective investigation and timely implementation of improvements remain key parts of preventing similar incidents in the future.
Why These Reports Matter
Every Prevention of Future Deaths Report begins with a family experiencing loss. However, the purpose of these reports is to look beyond the individual circumstances of a case and consider whether lessons can be learned that may help protect others.
For patients and families across Hull, Northern Lincolnshire and York & Scarborough, these reports provide an important insight into the issues coroners believe require attention. More importantly, they help ensure that concerns raised during an inquest have the potential to drive positive change and improve patient safety for future generations.
Prevention of Future Deaths Reports are frequently reviewed by healthcare organisations, regulators and legal professionals because they provide important insight into recurring safety risks, patient harm and opportunities for service improvement.
Key Findings from Local Prevention of Future Deaths Reports
Recent Prevention of Future Deaths Reports involving healthcare providers across Hull, Northern Lincolnshire and York & Scarborough commonly identify concerns relating to:
- Delays in recognising deteriorating patients
- Delayed diagnosis and treatment
- Safe discharge planning and follow-up care
- Falls prevention for elderly and vulnerable patients
- Communication and record-keeping failures
- Patient identification errors
- Staffing shortages and system pressures
- Learning from incidents and implementing improvements
Our Solicitors are Here to Help
If you believe that you or a loved one has suffered harm due to delayed diagnosis, surgical errors, failures in hospital care, maternity care concerns or another aspect of medical treatment, our specialist Medical Negligence team can provide clear, confidential advice about your legal options. We can also discuss whether you may be eligible for No Win, No Fee funding arrangements
You can contact our Medical Negligence solicitors on 0800 987 8800, complete our online enquiry form, or email medneg@bmcf.co.uk.
This article is based on information published by the Preventable Deaths Tracker and publicly available Prevention of Future Deaths Reports published by the Judiciary of England and Wales. By identifying concerns and encouraging action, Prevention of Future Deaths Reports remain an important tool in helping organisations learn lessons and improve patient safety for future patients.
