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Prevention of Future Death Reports for Suicide

05 May 2023
An analysis of Prevention of Future Death reports has revealed some clear themes across several organisations that need to be addressed in order to help prevent future deaths from occurring. 

When an individual has died, a Coroner has a duty to issue a Prevention of Future Death (PFD) report to the people or organisations that were involved in instances where the Coroner believes that there is a need to take action to prevent future deaths from occurring under similar circumstances.

For the first time, the Office of National Statistics has analysed the PFD reports available from 2021 and 2022, where the cause of death was suicide, to produce the "Prevention of Future Death Reports for Suicide" ("the Report").  The Report focuses on understanding the concerns that are most commonly raised by Coroners in the hope that this may inform future research or policies for suicide prevention.

In creating the Report, 96 PFD reports from 2021 were available and 68 from 2022.  Within these 164 reports, there were 485 different concerns identified by the coroners, with each report averaging three concerns. This article provides a summary of the findings of the Report. 

Organisations Addressed

A number of different organisations were addressed in the available reports, including the NHS, Government departments, the prison and probation service, police force and safeguarding agencies. The NHS was most frequently the recipient of a PFD report, with 69 reports out of 164 (42%) addressing the NHS as a concerning body, followed by government departments with 40 reports (24%) raising concerns. 

Coroners' Concerns

The Report grouped the concerns raised by the Coroners into 12 primary categories, and within these categories, analysed the recurrent themes.

The category subject to the most concerns was 'Processes', with 142 concerns raised over 89 reports, making this a concern across 54% of all reports. 'Inadequate monitoring and documenting of processes' was the most common theme, meaning that standard operating procedures had not been followed in these instances, or that processes were not being accurately recorded and clinical note taking not carried out, which potentially contributed to a death. Linked with this were 77 concerns relating to 'Policy', including instances where there was no relevant policy in place, or the policy that was in place was either inadequate or was not actually used in practice. 

32% of reports voiced concerns relating to the category of 'Access to Services'.  This includes themes such as delays in patients accessing services, and inadequate staffing. Lengthy wait times due to increased demand and not enough staff, or not enough qualified staff, were the biggest areas of concern that were jeopardising patients. Similarly, 'Culture' raised 28 concerns within the report, with inadequate ways of working, and failure to recruit and retain suitably qualified staff being the main concern. These factors led to issues such as procedures being signed off that had not actually been completed. 

'Assessment and clinical judgment' raised 78 concerns, in instances where a patient's history was not taken into account, or no risk assessment was undertaken. Concerns were also raised around failing to access patient information from the family or fully communicate between different services, leading to patient care plans being unclear or omitting important details.

Finally, a key theme related to the current training in place not being adequate, with staff training not being mandatory or training not sufficiently covering a topic or not being applied in practice. Similarly, 25 concerns were raised on the basis that recommendations from previous incidents were not being implemented in a timely manner.


This ONS's analysis into PFD reports is the first of its kind, revealing the wide range of concerns raised by Coroners following a suicide.  The most prevalent themes were that the available training was insufficient, communication between services was lacking and the monitoring and documenting of processes was inadequate. It is clear that review and improvement across these areas is required in order to help prevent future deaths from occurring. The DWF Regulatory, Compliance and Investigations team has a wealth of knowledge and experience with inquests and can advise on the prevention of future deaths.

If you require any further information regarding the above, then please contact Mark Thompson or Simon Belfield.

We would like to acknowledge the contribution of Lauren Parkinson to this article.

Further Reading