4 March 2024

There is no oversight, monitoring or analysis of what action or, indeed, inaction has followed such reports and their implementation. There is an accountability gap. It is morally pretty reprehensible that, in our experience, bereaved families have had to be proactive in trying to see how organisations have responded to the reports. 

Last month, INQUEST’s Director Deborah Coles presented evidence to a panel of MPs on the need for better oversight and follow-up to coroners’ warnings.

The Justice Select Committee launched a follow-up inquiry into The Coroner Service back in November 2023. The Committee’s aim has been to “build on and revisit” its previous report on the inquest system published in 2021, which called for major reforms to ensure bereaved people are placed at the heart of inquests.  

During an oral evidence session on 20 February 2024, the committee asked questions on coroners’ duty to issue Prevention of Future Death (PFD) reports where evidence from an inquest leads them to believe action should be taken to prevent future deaths. 

An ongoing area of considerable concern for INQUEST and many of the families we work with is the lack of proper oversight to coroners’ PFD reports. It is often extremely difficult for families and the wider public to learn exactly what action is being taken in response to a coroners concern.  

Further, there are instances in which inquests have raised the prevalence of repeated issues contributing to a death, which can have a deleterious impact on bereaved families whose objective in going through the inquest process, as Deborah told the Committee, is “truth and accountability, but it is also to try to protect other lives." 

Another growing concern for us is the non-self-inflicted deaths of people with learning disabilities or mental ill health who die following a choking incident. We are aware of 15 such cases since 2015, the issuing of nine PFD reports, and concerns about monitoring and management of risk. Yet people are still dying. That is the frustration, and that has informed the fact that we think there is a need for far greater analysis, dissemination and action in response to the reports. 

INQUEST is calling for the establishment of a National Oversight Mechanism to bring together the learning from inquests. A Mechanism would be a new, independent public body which would be tasked with collating, analysing and following up on PFD reports and inquest conclusions 

Our proposal for a Mechanism would also provide oversight and transparency to recommendations arising from investigations, public inquiries and official reviews following state-related deaths. You can learn more about our campaign here and sign our petition to establish a Mechanism here 

Deborah gave evidence alongside Dr Georgia Richard, a research fellow at the University of Oxford and founder of the Preventable Deaths Tracker 

The Committee also held a private meeting with several bereaved families to hear first-hand about their experiences of the Coroner Service. 

The Committee’s report on their inquiry to be published later this year.