Preventing future death reports by coroners should be legally enforced | NHS

Thank you for your article on how coroner reports on Prevention of Future Deaths (PFD) are routinely ignored (Coroner advice on maternal deaths is routinely ignored in England and Wales, according to study results published on November 19).

Experience has shown us that a coroner’s PFD report is produced in response to serious system failures and a trust’s inaction to prevent future tragedies. Tolerating poor care and refusing to learn appear to be common features of healthcare scandals, including the treatment of people with learning disabilities, such as our own beloved daughter, Juliet Saunderswho died at the age of 25.

She died because the local hospital misdiagnosed her and discharged her unsafely. The harrowing experience of the inquest was softened for us by the fact that the coroner saw that Julia was very loved and happy. The investigation uncovered a number of systemic deficiencies and clinical errors. The coroner rejected the trust’s own inquest. determined that neglect contributed to Julia’s death and issued a PFD with eight recommendations.

The trust resisted, claiming that Juliet was difficult to treat because she could not speak words. Would there have been improvements without the PFD? We were dismayed to discover that the promised measures were not legally enforced.

People with learning disabilities are three times older more likely to die for treatable reasons (preventable with appropriate healthcare) than the general population. The preventable death rate is almost double. Having seen how the NHS protects itself and vulnerable patients, we strongly believe that PFDs should be enforced by law.

We want no one else to die like Julia and no other parent to suffer the same grief. The fact that her death could have been avoided makes the cruelty even worse. We share this with all victims of health scandals.
Christine and Francis Saunders
Romford, Essex