The 14 organisations ‘named and shamed’ after failing to respond after deaths of 13 Londoners

Fifteen organisations have been named and shamed by the Chief Coroner’s Office after they failed to respond to concerns from local coroners. Authorities like councils, the police, and NHS Trusts usually have 56 days to respond to Prevention of Future Deaths reports (PFD), which are issued by presiding coroners at inquests where evidence emerges to suggest lives could still be in danger.

The reports are meant to highlight learnings from specific cases, and where the coroner is concerned about an ongoing issue that could lead to another avoidable fatality. Often the reports allow the media to write about important issues which have been been raised in court, but would otherwise go unreported if there was no reporter covering the inquest.

PFDs often concern some of the most sensitive deaths, including: deaths in state detention, deaths of children, suicides, and drug related fatalities. At MyLondon we have reported on failures by HMP Wandsworth and the Prison Service after the deaths of two prisoners in their cells; concerns about the safety of specialist mental health custody suites, and issues around NHS bed capacity.

An organisation that receives a PFD is expected to respond to the coroner in writing, explaining what steps they are taking (or have already taken) to mitigate against another tragedy, or to explain why no action is proposed. The Chief Coroner’s guidance, last updated in 2020, does not mention any consequence for failing to respond to a coroner’s report. It does, however, say the Chief Coroner may use the reports to identify an area of concern and advise action.

Dr Georgia Richards, an epidemiologist at King’s College London, previously told the Justice Committee more resources were needed to develop her Preventable Deaths Tracker, a centralised database of published coroner reports in England and Wales. Dr Richards suggested a ‘data-driven approach’ was needed to improve on the current system, reports Law Gazette.

Deborah Coles, director of INQUEST, a charity which provides expertise on state-related deaths and their investigation, also told the committee that PFDs are important because they can ‘inform improvements on public health’, including by taking local learning to a national level. But she described the absence of proper oversight and follow-up and analysis as ‘a real missed opportunity’.

A British Medical Journal article published in September last year suggested ‘there’s a growing body of opinion and evidence that the report system isn’t working as it should’ and claimed ‘there’s little evidence that these recommendations are being listened to’.

Non-responses

Naming and shaming the organisations who failed to respond to the coroner in 2024, judiciary officials wrote: “This report has been compiled after receiving confirmation from coroner’s offices that these responses have not been received. This report covers PFD responses due between 1 January 2024 – 13 December 2024.”

His Majesty’s Prison and Probation Service was a repeat offender, as was Barts Health NHS Foundation Trust.

The organisations (listed alongside the name of the deceased) were:

Got a tip, a court date, or some gossip? Please email callum.cuddeford@reachplc.com or WhatsApp 07580255582.

Don’t miss out on the latest crime stories from across London. Sign up to MyLondon’s Court & Crime newsletter HERE

Image Credits and Reference: https://www.mylondon.news/news/east-london-news/14-organisations-named-shamed-after-30772602