In April 2026, the Chief Coroner of England and Wales issued a formal policy entitled Prevention of Future Deaths Reports – Publication Policy (2026).[1] The policy sets out the approach to the publication, redaction and, in exceptional circumstances, non‑publication of Prevention of Future Deaths (“PFD”) reports and responses.
Fatalities from air accidents in England & Wales remain low and PFD reports in this context are correspondingly rare. The UK Air Accidents Investigation Branch ("AAIB") in its Annual Safety Review 2025 (published 5 June 2026),records 12 fatal air accidents in the UK in 2025, resulting in 18 fatalities. Of that number, four fatalities occurred in the commercial air transport sector. In the foreword, the Chief Inspector of Air Accidents notes, "safety is a perpetual challenge and investigations into accidents and serious incidents are needed to identify remaining vulnerabilities, understand new risks and help prevent future occurrences." [2]
Notwithstanding their relative rarity in aviation, PFD reports, when issued, can engage significant matters of regulatory compliance, operational practice and organisational decision‑making. The April 2026 Publication Policy is therefore of clear and direct relevance to those in the aviation industry, particularly in circumstances where coronial scrutiny intersects with AAIB safety investigation.
Prevention of Future Deaths reports: the statutory framework
The legal basis for PFD reports is well established, deriving from the Coroners and Justice Act 2009 and the Coroners (Investigations) Regulations 2013.[3]
A coroner in England and Wales is under a mandatory duty to issue a PFD report where, in the course of an investigation, the coroner forms the opinion that the circumstances disclosed give rise to a risk of future deaths occurring or continuing unless action is taken, and that action should be taken to eliminate or reduce that risk. The coroner’s discretion is limited to determining whether those statutory conditions are met. Once satisfied, the coroner must issue a report to any person or organisation, including regulators or public authorities, considered to have the power to take such action.
Recipients are subject to a separate mandatory obligation to provide a written response within 56 days (subject to extension), setting out any action taken or proposed, or explaining why no action is proposed. Reports and responses are provided to the Chief Coroner, who determines their publication.
Why was a formal publication policy required?
The introduction of the April 2026 policy reflects developments in both the use and practical significance of PFD reports.
First, the volume of PFD reports has increased over time. Ministry of Justice statistics record 569 PFD reports issued in England and Wales in 2023.[4] With increased numbers comes a corresponding need for a clear and structured framework governing their treatment.
Secondly, the accessibility of PFD reports has changed significantly. Since January 2023, reports and responses have been published on a searchable database maintained by the Judiciary of England and Wales. Since January 2026, full-text publication has further enhanced accessibility, enabling searches by key words and phrases. As a result, PFD reports now have significantly greater practical, reputational, and regulatory consequences for those to whom they are addressed.
Thirdly, transparency has been reinforced through additional measures, including the publication of twice‑yearly lists identifying recipients who have failed to respond within the statutory timeframe. This has further strengthened the accountability aspect of the PFD report regime.
The April 2026 Publication Policy
The Chief Coroner (Her Honour Judge Alexia Durran) sets out the position in clear terms:
“The decision to issue a PFD report is a judicial one. To comply with the principle of open justice, the public must be able to access PFD reports and responses, unless there is a compelling reason to restrict access… There is therefore a presumption that PFD reports and responses will be published by the Chief Coroner.”
There are three principal aspects of note:
- First, it gives formal effect to the principle of open justice by establishing a clear presumption in favour of publication. Reports and responses are accessible unless a compelling justification for restriction arises.
- Secondly, it provides a clear framework governing the exercise of the Chief Coroner’s discretion introducing consistent criteria for publication, redaction and (in exceptional cases) non‑publication. The aim is to promote transparency, predictability, and principled uniformity in decision‑making as regards publication.
- Thirdly, it strengthens the accountability and preventative function of the PFD regime by ensuring that reports and responses are accessible and so available for scrutiny. This facilitates the identification and dissemination of lessons of wider relevance.
Aviation‑related PFD reports
Most PFD reports concern sectors outside aviation, including healthcare, workplace fatalities, road transport and deaths in custody and detention. Only a small proportion relate, directly or indirectly, to aviation. These include reports arising from air accident fatalities, incidents at aerodromes or airports, and fatalities connected with aircraft maintenance, ground operations, or aviation‑related occupational activity. In the context of air accident fatalities, coroners do not revisit technical causation, which falls within the statutory remit of the AAIB. Instead, the focus is on broader risks disclosed by the death, including systemic or regulatory issues and whether steps should be taken to mitigate the risk of recurrence.
Illustrative examples
The following examples demonstrate how PFD reporting have arisen and in an air accident context, have done so alongside but separately from AAIB investigation:
- A fatal hot air balloon accident in June 2023 led to an AAIB final report in May 2024. Separately, a PFD report issued in August 2024 addressed concerns regarding regulatory oversight and competitive ballooning practices. This contributed to subsequent CAA activity and the publication of safety guidance for balloon events and competitions (CAP 1739) in April 2026.[5]
- In the Shoreham Airshow accident (2015), a Hawker Hunter aircraft crashed during a display. The aircraft crashed on the A27 adjacent to the airshow ground resulting in eleven fatalities and injuring some sixteen others. PFD reports addressed risks within the regulatory framework governing flying displays. These reports contributed to significant revisions to CAA regulatory guidance CAP 403.[6]
- PFD reports have also featured in an aviation-adjacent context. In 2025, the Senior Coroner for Inner West London issued a PFD report following the repatriation of victims of the Air India 2025 fatal accident. The report identified a serious and previously under‑recognised public health risk arising from the repatriation of human remains. The report addressed risks arising from elevated levels of toxic substances (including formalin) within coffins. The report led to clarification of procedures and strengthened protective measures for UK mortuary staff and others handling repatriated remains.
Conclusion
The April 2026 Publication Policy confirms that publication and transparency are now central features of the PFD regime.
For aviation stakeholders, this carries implications. Although PFD reports arising from aviation fatalities remain uncommon, their potential impact is significant. They may concern regulatory issues, operational practices and organisational decision‑making. Secondly, they can attract public, media and regulatory scrutiny beyond the conclusions and recommendations of the AAIB investigation into accident cause or associated coronial inquests establishing how, when and where the deceased came to their death.
Accordingly, PFD reports, where they do arise, should be understood as an additional aspect of post‑incident exposure. They introduce a further layer of legal, reputational, and operational risk which requires active management, alongside existing post-loss investigative, regulatory and claims processes. Consideration of potential PFD engagement, and the associated time, cost and resourcing implications, should therefore form part of the broader response and risk management strategy adopted by aviation industry parties in the aftermath of a fatal accident.
[1] Chief Coroner of England and Wales, Prevention of Future Deaths Reports – Publication Policy (2026), Courts and Tribunals Judiciary, April 2026.
[2] Air Accidents Investigation Branch, Annual Safety Review 2025 (AAIB, 4 June 2026).
[3] Coroners and Justice Act 2009, c. 25, Coroners and Justice Act 2009, c. 25, and the Coroners (Investigations) Regulations 2013 (SI 2013/1629).
[4] Ministry of Justice, Coroners Statistics 2023: England and Wales (published 10 May 2024).
[5] Civil Aviation Authority, CAP 1739: Safety Guidance for Balloon Events and Competitions (2026).
[6] Civil Aviation Authority, CAP 403: Flying Displays and Special Events (as amended).
