Coroners are under a duty to make a Prevention of Future Deaths (PFD) report (also known as a regulation 28 report) when they are concerned that further deaths may occur and action needs to be taken to prevent this. All reports and responses must be sent to the Chief Coroner and in most cases they will be published on the Chief Coroner’s website.

The review from our experts considers key themes from PFD reports issued during the period from1 March 2023 to 31 August 2023, concerning hospital related deaths (clinical procedure and medical management).

In a more in-depth analysis, we highlight a selection of issues from the top three categories by frequency to inform patient safety and learning to prevent future harm.