BBK Manifesto 2026: Introduce consequences for organisations that fail to act on Prevention of Future Death reports
When a coroner issues a Prevention of Future Deaths (PFD) report, it is because they believe action could prevent similar fatalities in the future. These reports are only made in exceptional circumstances, yet too many organisations still fail to respond despite having an obligation to do so. To protect the public and ensure lessons are learned, the Government must introduce meaningful consequences for organisations that ignore these important warnings.
Naming and shaming is not enough
In January 2025, the Chief Coroner, HHJ Alexia Durran, introduced the first “badge of dishonour” list, publicly identifying organisations that had failed to respond to PFD reports within the statutory 56-day deadline. Many of those named were from the health and care sectors.
According to the Preventable Deaths Tracker, around 80% of PFD reports received a response between August 2025 and August 2026 compared to an 89% response rate in the year prior. The evidence suggests the current approach is not achieving its intended effect.
One in five reports receives no response, and the overall level of compliance appears to have declined since the introduction of the new measures. Given that PFDs are only issued where a coroner believes improvements could prevent future deaths, this level of non-compliance remains unacceptable.
The scale of the problem
Since July 2013, coroners in England and Wales have published more than 6,300 PFD reports, but just 64.4% have received a full, publicly available response during that time, according to the Preventable Deaths Tracker.
Recipients of a PFD report are under an obligation to explain what action has been taken, what action will be taken and when, or why no action is proposed.
However, once a PFD has been issued, coroners have no legal powers to take further action if the recipient fails to respond or implement changes.
The impact on bereaved families
For families who have lost a loved one, a PFD can provide reassurance that their death may help prevent similar tragedies. When organisations fail to respond, families are left wondering whether important lessons have been ignored and whether the same failings could happen again.
Stronger oversight is needed
Although public naming ought to have encouraged greater compliance by strengthening public accountability, the evidence indicates this is not the case in practice. There remains no mechanism to ensure responses are provided or that improvements are actually implemented.
As part of our Manifesto for Injured People, we believe a regulator should be introduced to oversee compliance with PFD reports and ensure recommendations are acted upon. This would require additional funding, recognising that coroner services are already under significant resource pressure, as demonstrated by the continuing delays within the coroners’ courts.
Organisations that willfully or repeatedly ignore PFD reports should face proportionate but meaningful sanctions, including criminal penalties for the most serious and systemic failures. Without meaningful consequences, there is little to deter organisations from disregarding warnings intended to save lives.
Growing political attention
The issue has now been raised in Parliament. During proceedings in the House of Commons on 14 July 2026, the Government said it is working with the Cabinet Office to improve responses to PFD reports issued to Government departments.
The bottom line
Prevention of Future Deaths reports are intended to save lives. Organisations already have an obligation to respond, but without any enforcement powers, too many continue to ignore them. Public naming has not solved the problem.
The next step must be stronger oversight and meaningful accountability to ensure these reports result in action rather than being overlooked.
This blog is part of our 2026/27 Manifesto for Injured People. At Bolt Burdon Kemp, we support injured people not only by winning their cases but by driving positive change. Guided by our clients’ experiences and partnerships with charities across the UK, we are raising awareness of the changes needed to better support injured people. We will continue working with politicians from all parties to ensure injured people’s needs are not overlooked in Westminster or beyond. You can read our full manifesto here.
