There has been a notifiable increase in Prevention of Future Deaths Reports (PFDs) in recent years, with a significant number involving care homes/providers. This trend reflects a renewed emphasis on the coroner’s duty to highlight risks uncovered during inquests. For care providers, the message is clear: scrutiny is intensifying, and the sector must respond proactively.
 

Key Themes Emerging from Recent PFDs

Coroners have repeatedly raised concerns relating to the same issues following unexpected deaths in care settings. The most common issues include:

• Inadequate risk assessments and poor risk mitigation
• Incomplete or inaccurate record-keeping
• Failure to follow eating, drinking, and care plans
• Delays in seeking medical attention
• Unsuitable placements or insufficient staffing levels, including missed 1:1 care needs
   

Reducing Risk Before — and After — an Incident

Whilst an inquest does not assign civil or criminal liability, it can trigger new or renewed police/Health and Safety Executive investigations, reputational damage, regulatory action, and/or civil litigation by the family. These are serious and real risks which we recommend are accounted for before providers are in the midst of a storm as this consideration may just prevent a future death from occurring. With this in mind, care providers can work to eradicate/mitigate these risks by:

• Strengthening and robustly monitoring compliance with policies, training and care plans.
• Appropriately completing and updating care plans, risk assessments and personal emergency evacuation plans.
• Ensuring robust and accurate record keeping and handovers.
• Managing HR issues sensitively
• Appropriately communicating with staff and advising them of who to refer media queries to.
• Learning lessons from shortfalls in service/policy compliance and implementing changes.

When the worst occurs, it is imperative that the incident is escalated to a senior member of staff to manage and lead any internal investigation. Whether an investigation is appropriate will depend on the circumstances, and we recommend that providers consider obtaining legal advice on this point because of the risk of overlaying investigations, and the need to avoid prejudicing your own position.
 

CQC Implications: Transparency Is Essential

It is important to note that PFDs are often shared with the Care Quality Commission, potentially triggering formal investigation or regulatory sanctions. Care providers must ensure that all regulatory requirements have been met, including compulsory notifications, and that the Duty of Candour is complied with if applicable.
 

Takeaway for Providers

The rise in PFDs is a clear signal: care homes must demonstrate robust governance, responsive learning, and unwavering commitment to resident safety. Acting early and seeking early legal advice helps protect both residents and organisations from avoidable harm and scrutiny.

Samantha Grix, Partner and Narin Masera, Solicitor both of Devonshires Solicitors LLP