Coroner's Court & Prevention of Future Deaths Reports

What is a coroner's inquest?

A coroner investigates deaths that are sudden, unexplained, violent, or occur in custody. Under the Coroners and Justice Act 2009, an inquest must be opened where the coroner has reason to suspect the deceased died a violent or unnatural death, the cause of death is unknown, or the person died in custody or state detention.

The inquest is inquisitorial — the coroner directs proceedings and calls witnesses. There are no parties in the traditional adversarial sense, though interested persons (including families and public bodies) are represented by lawyers and can ask questions. The coroner returns a conclusion, not a verdict.

Hearings are open to the public and press. INQUEST, the charity supporting bereaved families, publishes guidance on inquest procedure at inquest.org.uk.

Types of inquest and conclusions

Prevention of Future Deaths reports (Regulation 28)

A Prevention of Future Deaths report is issued when a coroner believes there is a risk of further deaths unless action is taken. The coroner sends the PFD report to the person or organisation with the power to act — a hospital trust, a government department, a manufacturer, a local authority.

The recipient has 56 days to respond. Both the PFD report and the response are published by the judiciary at judiciary.gov.uk/prevention-of-future-death-reports. The database is searchable by date and subject.

PFD reports are an excellent source of accountability journalism. They identify specific systemic failures, name the organisations responsible for responding, and create a public record of what those organisations did — or failed to do — in response. A series of PFD reports to the same organisation on similar issues is a powerful investigative thread.

Accessing inquest hearings and documents

• ›Inquests are listed by the local coroner's office — there is no national centralised listing. Contact the relevant coroner's office for upcoming hearings.
• ›The Chief Coroner's Office publishes guidance and statistics at judiciary.gov.uk/courts-and-tribunals/coroners-courts/.
• ›Documents disclosed during an inquest are not automatically available to the press — you must apply to the coroner. The family of the deceased often has access to pre-inquest documents; approach them directly.
• ›The coroner's record (formerly called the inquest file) can be requested via the coroner's office after proceedings are complete. There may be a fee.
• ›FOI requests to the coroner are generally subject to the Coroners Act exemption under FOIA 2000 s.32, but pre-inquest disclosure requests have had mixed success.

What to focus on when reporting an inquest

• 1The conclusion — including whether it is short-form or narrative, and what the narrative says about how the death occurred.
• 2Any critical comments by the coroner about the actions of public bodies, hospitals, or agencies — these are often the most significant parts of the hearing.
• 3Any PFD report issued — this is the coroner's formal statement of what needs to change.
• 4The response (or failure to respond) of the named organisations to previous PFD reports.
• 5The family's reaction — they are often willing to speak and their perspective gives human context to what might otherwise be dry procedural findings.
• 6Whether this death is part of a pattern — search the PFD database for similar reports before writing.

Common reporting errors to avoid

• ⚠Describing the conclusion as a "verdict" — inquests return conclusions, not verdicts.
• ⚠Saying the inquest found someone "responsible" for the death — an unlawful killing conclusion does not identify a named individual as criminally responsible.
• ⚠Failing to distinguish between the conclusion and the coroner's narrative — a narrative finding may be more critical than the formal short-form conclusion.
• ⚠Confusing a PFD report with a finding of fault — a PFD is a preventative measure, not a determination of liability.
• ⚠Reporting suicide conclusions in a way that breaches the Samaritans' media guidelines on responsible reporting of suicide.

Pre-publication checklist for inquest reporting

• I have confirmed the stage of proceedings — is the inquest still open, adjourned, or concluded?
• I have distinguished the formal conclusion from any narrative finding — they may be different in emphasis.
• I have checked whether a PFD report has been issued and identified the named recipient(s).
• I have noted any response — or absence of response — from the PFD recipient.
• Where the conclusion is suicide, I have followed the Samaritans' media guidelines on responsible reporting.
• I have not described the conclusion as a "verdict" — the correct term is "conclusion" or "finding".
• Where criminal proceedings arising from the same death are possible or pending, I have applied the strict liability contempt test.

Related guides

Frequently asked questions