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Coroners Prevention of Future Deaths Reports Jan 2019 to May 2025

Reference: 24-25054

Date response sent: 23/05/2025

Details of enquiry

  1. Please send me a copy of every PFD relating to suicide that the Trust received. Please include PFDs received where the Trust was a listed addressee and/or where the Trust was copied for information as an ‘interested person’.
  2. Please also send me a copy of the Trust’s response to each PFD, clearly marking to which PFD the response refers.
  3. Please send me a copy of any internal correspondence which relates to each PFD, clearly marking to which PFD the correspondence refers.  This should include:

a. Minutes from meetings

b. Email conversations between staff and contractors

c. Details of any staff training undertaken

d. Memos sent

Response sent

  1. Please send me a copy of every PFD relating to suicide that the Trust received. Please include PFDs received where the Trust was a listed addressee and/or where the Trust was copied for information as an ‘interested person’.

a. The Trust confirms that it holds this data.

b. The Trust confirms that it was named in a Regulation 28 report in ≤5 instances, ≤5 of which was concluded, by coroner, as not being a death by suicide.

c. The Trust confirms that it was named as an interested person in ≤5 case.

Explanation of ≤5

We have masked low numbers with the symbol ‘≤5’, which indicates where numbers are equal to 5 or less than 5. The Trust follows the NHS England standard, established to not provide exact data where the numbers are smaller than 6 as this may nevertheless give rise to a disclosure of the deceased’s identity:

  • we have to consider whether other information that is already available, or may become available, to any member of the public, could be combined with the data requested so as to enable identification of the individual(s) concerned.
  • There is a high chance of recognition/identification of particular individuals/patients by fellow patients/colleagues and/or others from the low numbers, and likely to be used by a determined person with a particular reason to want to identify individuals from data in the public domain now or in the future, and/or gained from other sources.
  • To avoid risk of alarming stories about suicide causing distress to people who are themselves at risk of suicide
  • identification – when someone sees in themselves a connection with a person who has died by suicide; leading to imitation and suicide clusters in people with similar characteristics

The Trust is withholding copies of all Suicide related Coroners’ Prevention of Future Deaths Reports (PFDs or Reg 28 letters) PDFs or related Minutes, Emails Training or Memo’s in accordance with Section 2: The Common Law of Confidentiality and Consent by which all NHS Trusts must abide, and by which confidentiality extends after the death of individuals who may have received services from the Trust.

Whilst Coroners reports are largely publicly available, under other legal frameworks, they are not disclosable, under the Common Law of Confidentiality and Consent, as to do so would constitute a breach in adherence.

You might find it helpful to review our response to a previous applicant (November 2024) 24-25319 Prevention-of-Future-Deaths-Reports-2013-24 where you will see that the Trust has received a relatively small number of coroner’s reports on suicide.

The Trust acknowledges that exemption from disclosure under s40 and s41 (personal data) of the Freedom of Information Act 2000 (FOIA) does not apply to data about deceased patients,

Whilst Coroners reports are largely publicly available under other legal frameworks, the Trust confirms that they are not disclosable, under the Common Law of Confidentiality and Consent, as to do so would constitute a breach in adherence.

To access these reports, you may wish to try and/or retry either of the following publicly available links; one shows data by name of the deceased, and the other shows a listing by Trust.

i. Reports to Prevent Future Deaths – Courts and Tribunals Judiciary searchable by deceased’s name, and includes where an organisation may have responded

ii. Reg 28 Reports Tracker Database – Preventable Deaths Tracker

Searchable by any of the fields which sort into alphabetical order, by clicking on any column header. Also available for reuse as a purchase.

The Trust notes that you reported encountering difficulties in obtaining the Coroner’s reports on specific individuals, so in order to be helpful to you we have suggested below some additional ways that you may wish to seek Coroners Reports on their own, as there are other Acts which do permit certain authorities,(but not NHS Trusts), to reveal data on deceased persons under certain criteria, for example:

i. The Public Records Act 1958, places an ethical obligation to the relatives of the deceased exists, which permits the use and disclosure of the information within them in only limited circumstances.

ii. The Access to Health Records Act 1990 permits access to the records of a deceased person by those with a claim arising out of that individual’s death.  This right of access is negated however if the deceased individual concerned requested that a note denying access be included within the record prior to their death (this might be part of a formal advance directive).

iii. Local authorities generally provide access to social care records through the Freedom of Information Act as there is no equivalent statutory provision to the Common Law of Confidentiality and Consent in relation to social care records. However, the guidance issued by the Information Commissioner’s Office (ICO) on s.41 of the Freedom of Information Act (FOIA) means that relatives could pursue a case for breach of confidence ICO: Practical guidance: Information about the deceased).

iv. Whenever Inquests are held, linked to a Prevention of Future Deaths report (Regulation 28 Report to Prevent Future Deaths), the name of the deceased will be published and placed into the public domain by a coroner. This does not cover every death in the country.

  1. Please also send me a copy of the Trust’s response to each PFD, clearly marking to which PFD the response refers.

Please see our response to Question 1 above.

The Trust is withholding this information of all Trust correspondence to all Coroner’s Prevention of Future Deaths Reports in line with its adherence to with Section 2: The Common Law of Confidentiality and Consent by which all NHS Trusts must abide, and by which confidentiality extends after the death of individuals who may have received services from the Trust.

  1. Please send me a copy of any internal correspondence which relates to each PFD, clearly marking to which PFD the correspondence refers.  This should include:

a. Minutes from meetings

b. Email conversations between staff and contractors

c. Details of any staff training undertaken

d. Memos sent

Please see our responses to Questions 1 and 2 above.

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