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Helping bereaved families get answers at inquests and the campaign for a national structure to ensure care improvement recommendations are upheld

It’s impossible to comprehend how a family must feel when they learn that the death of their loved one could have been prevented.  I often consider how this knowledge affects their grief journey, but I’m sure that it must. 

As a lawyer who represents those who are bereaved at inquests, I’m humbled by each family that I work with and the resilience and strength they show as they navigate the inquest. But what happens after an inquest? What happens if the family of a loved one discovers that a death could have been avoided?

Prevention of Future Death reports 

Coroners have a duty to prepare a report to a person, organisation, local authority, or government department or agency where it’s believed that actions should be taken to prevent future deaths. These Prevention of Future Death reports (PFD) – also known as Regulation 28 reports - are sent to the Chief Coroner and allow for recommendations to be made by a coroner to effect change. 

Recipients of a PFD are under a legal duty to review the report and respond to the coroner but there are no sanctions or penalties if they don’t. 

Campaign for national oversight to monitor coroners' recommendations

There is currently no national oversight to monitor recommendations and PFDs made by coroners, so how can families be assured that changes will be made and monitored?  Who is accountable and how can concerns be raised? 

It’s imperative that a post-death independent body is implemented to monitor, analyse, and track recommendations made by a coroner because of a death or PFD. The charity INQUEST which supports bereaved families, is calling for a National Independent Oversight Mechanism to hold recipients of PFDs and recommendations to account. 

I wholeheartedly agree that this structure would provide better learning, prevention, transparency, and accountability for bereaved families following a state related death. 

Families often left needing answers to their concerns

Bereaved families that I’ve represented at inquests tell me that the main reasons they ask for my legal help is to greater understand what happened to their loved one and to seek to hold the relevant organisations accountable where failings in the standard of care have been identified. 

Written evidence has now been published on The Coroner Service and of course is being hotly debated in the House of Commons. To me it seems obvious, the need for a more robust framework to implement the recommendations following a death needs to be actioned urgently. 

Supporting families

Earlier this year I represented Lauren, the partner of Nathan Cunliffe.  Nathan was an inpatient in a mental health unit at Hollins Park Hospital. In January 2022, Nathan absconded over an eight-foot-high fence before dying by suicide. The jury at the inquest into Nathan’s death raised concerns about the lack of an environmental risk assessment, including the height of the fence being too low. 

The Department of Health is being asked to issue safety guidelines on recommendations of the height of such fences following several other deaths of young men in similar circumstances. 

Lauren stands by the campaign to provide better scrutiny of the learning outcomes following an inquest, to stop other families going through what she has.

Find out more about our expertise in supporting families at inquests following the death of a loved one in a medical setting at our dedicated medical negligence inquests section. More information about how we support loved ones following a death of a person detained by the state is also available at our protecting your rights section.