By Gill Weatherill, Tracey Longfield, Louise Wiltshire & Gemma Brannigan


Published 24 April 2023


The purpose of Prevention of Future Deaths Reports (PFDs) issued by coroners is to bring about positive change by promoting learning from deaths.  However, to capitalise fully on the power of PFDs to drive improvements in care, the lessons learned from those cases need to be shared across the system.

To help shine a light on the current picture, this time last year we published a report on themes we identified from PFDs issued to health and social care providers in 2021.  Having received positive feedback about the usefulness of that exercise, we have repeated it this year by looking at themes arising from PFDs issued during the course of 2022 in relation to acute hospitals, mental health, social care and ambulance services.

Click here to see what we found.