Understanding Depth

An article was published recently in the Guardian which argues the depth of the NHS’s difficulties can be seen through coroners reports, known as Preventing Future Death (PFD) reports.  This is not new to anyone who is a regular reader of this blog and there is so much work that I would love to spend time doing, analysing the details of PFDs which are directly relevant to the subject of this blog.  You will notice within the PFD link just posted there are a number of cases where I’ve given further links to individual deaths after police custody or contact, high profile events where we remember hearing that lessons would be learned but that claim is bold, to say the least.  I also have a list of other PFDs to add to this list when I find the time.

The problem being observed by the Guardian is not just the number of PFDs from Coroners indicating factors contributing to deaths, but it hints at the number of repeat problems arising from systemic factors.  It’s common after tragedies where public agencies were argued to have fallen short of what was required to suggest that “lessons will be learned” and to hear families campaigning after the worst of all tragedies losing a loved one, that such things “can never happen again to another family”, or similar, heartbreaking sentiment.

The Guardian article doesn’t focus on mental health or policing.  In fact, the first emphasis it highlights is on ambulance delays which were argued as relevant to 24 or 55 deaths they examined.  But if you were to go to the website of the Chief Coroner and do your own examinations, you’d find plenty of systematic and repeat factors to think about.


  • Joint protocols – in all areas there should be a joint protocol between Chief Constables and their statutory partners (mental health trusts, local authorities as well as ambulance and acute trusts, where relevant) on five topics.  PFDs have repeatedly shown that such policies are deficient, not well understood or simply absent.  Of course, even where they do exist in whatever form, staff need to be aware they exist and be aware of or trained in their content.
  • Legal detail – we see Coroners highlighting legal problems, whether that be legal compliance with s140 or s13 MHA or whether it relates to frontline professionals being aware of legal responsibilities or options.  Indeed, what’s interesting in some agencies responses to Coroners, is their resistance to what the Coroner has pointed out, which does touch inevitably on their ability or willingness to prevent the future deaths about the Coroner is concerned.
  • Training – we now that staff aren’t trained.  They just aren’t and this isn’t my opinion – it has been reflected in reports by His Majesty’s Inspectorate of Constabulary that College of Policing training (2016) after the Crisis Care Concordat (2014) was, basically, not trained out.  We keep seeing inquests where officers claim in evidence that they were not trained in the joint protocols which existed or in the detail of mental health and capacity law.
  • Mental health beds – the police service has been connected to inquests where a lack of inpatient beds was the barrier to keeping people safe.  Indeed on occasion, the police were being looked at by other agencies to plug the gap that exists because our colleagues who go out ‘AMHPing’ are not being told by NHS bed managers of the hospitals to which they should be making their MHA applications where necessary.  Including where urgently necessary.

Of course the mental health beds issues goes way beyond policing: there are plenty of PFDs on the Chief Coroner’s website which touch upon mental health services only, where patients were in the community after being assessed for admission and where the barrier was a lack of available inpatient  facilities. I’m not sure if people realise how many patients who need to be ‘sectioned’ are in fact, still at home with families, pending beds being found for admission.  It should be remember that a decision to ‘section’ someone is, by defintion, a decision that community care is not appropriate and not consistent with safety.

There are other themes in the PFDs, but this is enough to make the point.


There is no national oversight mechanism for the distribution and learning from PFDs – something for which the charity Inquest is campaigning.  The Chief Coroner’s Office uploads them (and the responses to them) where they can, but as the loading of responses is not always done, I have to infer there are resource problems in staying on top of all notices and all responses.  Whether PFDs are distributed to relevant agencies is also unclear – the individual notices from a particular inquest is sent, of course, to the agencies identified in that inquest as relevant and they are often copied to national figures like ministers or a national body like the College of Policing.

How, though, would we be confident that police force X in the north of England had learned from a PFD issued by a Coroner in police force Y in the south of England?  Perhaps more complicatedly, how would we be sure that mental health trust X was reading a PFD from area Y if the inquest did not involved mental health trust Y as an ‘interested party’?  An interested party is a person or organisation of direct relevance to the proceedings but we do know, for example, that some inquests focus upon joint protocols which were authored within mental health trusts before being agreed across a partnership area, only for them not to be an interested party at the inquest because they were not directly involved on the day with the person who died.

In fairness, if you were a senior mental health manager in area X who was keeping an eye on PFD notices in mental health services, why would notice a PFD from area Y and think it relevant if it wasn’t sent to the equivalent service in area X?  Yet the content can be relevant.  And finally, I’ve always been curious why PFDs flagging ongoing legal problems doesn’t seem to lead to intervention by regulators who oversee the effective operation of our legislation.


For example, more than one PFD has highlighted the lack of inpatient beds, more than one of those has highlighted problems with s140 MHA (designation of hospitals to receive patients urgently) and more than one has highlighted delays by AMHP services in conducting MHA assessments or making applications, precisely because AMHPs are aware there are no beds.  We know many of these hearings have been “Article 2“ inquests because they revolved around the state’s obligation to protect the right to life.  Indeed we know in more than one case, families have brought civil litigation against organisations for an Article 2 breach and won, arising from failures featured in the themes above after inquests found significant problems, inc neglect (by the organisations, not usually by individual staff).

It seems reasonable of organisations like Inquest to wonder what really happens with PFDs, given how much of their work is supporting families whose tragedies are, to say the least, very similar to previous tragedies seen in the Coronial process.  I must admit, I do also wonder and that’s why I’d like to do much more work on this, once I have the time.

NB: I have deliberately not linked to individual tragedies and PFDs in this article — those details are available elsewhere on the blog if you’re interested in detail.

Winner of the President’s Medal, the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award


All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown, 2023

I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current.  Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.

Government legislation website – www.legislation.gov.uk