Prevention of Future Deaths
Expert psychiatric evaluation for a Prevention of Future Deaths report — addressing clinical governance and risk management within Coronial proceedings. We provide specialist insights into systemic failures with urgent reports available for legal teams.
Expert Type
- Forensic Psychiatrist
- Clinical Psychologist
- Neuropsychologist
- Registered Nurse (Forensic/Mental Health)
Applicable Law
- Coroners and Justice Act 2009
- The Coroners (Inquests) Rules 2013
- Chief Coroner’s Guidance No. 5
- Human Rights Act 1998 (Article 2)
When Needed
This assessment is required when a Coroner identifies a risk that other deaths will occur unless remedial action is taken by an organisation.
What Is a Prevention of Future Deaths Assessment?
A Prevention of Future Deaths (PFD) assessment involves a critical review of the circumstances surrounding a fatality to identify systemic failures. It focuses on the clinical governance and risk assessment protocols that were in place at the time of the incident to determine if future lives remain at risk.
The legal duty arises under Paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009, requiring Coroners to report concerns where action is needed to prevent recurrence. This requires an expert to evaluate operational policies and individual clinical decisions to provide an objective opinion on service safety.
- Risk identification — identifying ongoing hazards to life within a service
- Systemic analysis — evaluating whether failures were individual or institutional in nature
- Policy compliance — assessing adherence to national and local clinical guidelines
- Causality assessment — determining the link between service failures and the fatality
- Mitigation strategies — proposing specific, actionable changes to prevent future harm
- Article 2 compliance — ensuring the state’s duty to protect life is scrutinized effectively
Expert witnesses in these cases must possess significant clinical experience and an understanding of the Coronial process to provide credible testimony. They act as independent advisors to help the court understand complex medical negligence or systemic issues.
The resulting expert opinion serves as a catalyst for institutional change, ensuring that lessons learned are translated into robust safety improvements across the healthcare sector and forensic services.
Key Assessment Components
Our assessment evaluates the following areas:
Root Cause Analysis
A thorough investigation into the contributory factors and underlying triggers that led to the clinical incident.
Risk Assessment Review
Evaluating the adequacy of risk management tools and their practical application in the specific case.
Policy Audit
Comparing the standard of care provided against established NICE guidelines and local trust protocols.
Staff Competency Evaluation
Assessing whether professional training and supervision levels were sufficient to ensure patient safety.
Environmental Safety
Reviewing the physical environment for hazards, such as ligature points or inadequate observation capabilities in secure settings.
Recommendations for Change
Formulating evidence-based interventions designed to eliminate identified risks and improve future outcomes.
Conditions That May Affect This Assessment
A range of psychiatric and psychological conditions can affect this assessment. These include:
The impact of these conditions often depends on the clinical setting and the specific care pathway administered to the patient.
Assessment Process
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Instruction Received
We receive formal instructions from the solicitor or Coroner, detailing the scope of the PFD concerns.
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Expert Matched
We assign a forensic expert with specific experience in the relevant clinical setting and systemic auditing.
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Assessment Conducted
The expert reviews medical records, policies, and witness statements to identify procedural or clinical gaps.
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Report Delivered
A comprehensive report prepared in accordance with applicable Coronial procedural requirements is issued, highlighting risks and suggesting preventative measures.
Turnaround Times
| Urgency Level | Timescale |
|---|---|
| Standard Report | 4-6 weeks from assessment |
| Priority Report | 1-2 weeks |
| Urgent Report | 1-4 days |
What’s Included in the Report
All reports are of the highest evidentiary standard and our experts are available for oral testimony at Inquests.
Frequently Asked Questions
Need a Prevention of Future Deaths Report?
Contact us today for expert psychiatric evidence tailored to Coronial inquiries. We provide CVs and quotes within 60 minutes of your instruction.
Related Inquests & Inquiries Services
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Detailed evaluations of violence, self-harm, and suicide risk profiles.
Systematic investigation of serious incidents within healthcare services.
Reviewing the mental state and care of a deceased person prior to death.
Expert reports on whether clinical professionals adhered to their duty of care.
