Are the recommendations in coronial prevention of future death (PFD) reports realistic and achievable?

Prevention is better than cure. Coroners are not often thought to have a role in prevention, even though they have a duty to produce prevention of future death reports. Such reports are supposed to stimulate changes to prevent further deaths from recognised problems, but we speculated that they do not achieve their purpose. The reports are categorised, published online and are publicly available. This study set out to analyse prevention of future death reports to understand how far they prompt change, in two healthcare-related categories. Reports dated in 2020 were reviewed and data were collated detailing the contents of each one and whether there was a response. Results showed that the prevention of future death reports are inconsistent with regard to the details they included and there is no evidence that concerns raised by Coroners stimulate significant, widespread change in the healthcare system.