“which are being reported to the addressees”

The coroner’s concerns

which are being reported to the addressees. Each matter of concern 4 is denoted by an “MC” reference and is highlighted in bold. In each instance, the public authorities (and, in one case, an industry body) to which the point is addressed are identified. 17. In preparing this Report, I have taken into account submissions from the bereaved families of what matters I should consider raising and the responsive submissions from other Interested Persons. The need to give time for those submissions and to consider them explains why this Report is being issued some months after the end of the Inquests. 18. In this Report, I shall explain what matters of concern I am raising and shall also address points raised by the bereaved families which do not in my view justify inclusion as matters of concern in a PFD Report. It is not normal practice for coroners to include in such reports explanations for not including certain matters. PFD Reports of coroners generally are, and should continue to be, short and succinct documents produced quickly after inquests. This report by contrast is an extensive document, as is appropriate to these exceptional Inquests (just as Hallett LJ produced a lengthy PFD Report following the London Bombings Inquests). It should not be seen as a model for inquests generally. Legal Principles 19. Before addressing the particular topics relevant to this Report, I shall set out the applicable legal principles. In doing so, I shall largely adopt the submissions of Counsel to the Inquests, which have not been disputed by Interested Persons in their submissions. Again, I should acknowledge that it is not normal practice for coroners to set out the law in PFD Reports. The wide public interest in this Report warrants including an explanation of the law. 20. Schedule 5 to the CJA, which is given effect by section 32, provides as follows at paragraph 7: (1) Where – (a) a senior coroner has been conducting an investigation under this Part into a person’s death, 5 (b) anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and (c) in the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances, the coroner must report the matter to a person who the coroner believes may have power to take such action.” 21. Part 7 of the Regulations contains provisions for the making of PFD Reports. Regulation 28 provides as follows: “(1) This regulation applies where a coroner is under a duty under paragraph 7(1) of Schedule 5 to make a report to prevent other deaths. 22. (2) In this regulation, a reference to ‘a report’ means a report to prevent other deaths made by the coroner. (3) A report may not be made until the coroner has considered all the documents, evidence and information that in the opinion of the coroner are relevant to the investigation.” The following principles govern the making of PFD Reports: (a) The regime provides for a coroner to make a report if he/she forms the view that a risk of future deaths can be seen and that preventive action ought to be taken. If he/she forms that view, it is necessary to make a report with the relevant content. That is the effect of the words “must report” in paragraph 7(1). See R (Lewis) v Mid and North Shropshire Coroner [2010] 1 WLR 1836 at [14]-[16] and [19]. (b) The power and duty to make a report only arise where the coroner forms the opinion, based on his/her inquiry, that particular risks of death exist for which preventive action is required. As Silber J said in R (Cairns) v HM Deputy Coroner for Inner West London [2011] EWHC 2890 (Admin) at [74], the statutory expression “in the coroner’s opinion, action should be taken…” reflects a discretionary judgment by the coroner. 6 (c) The jurisdiction to make PFD Reports is not limited to reporting circumstances and risks which were causally relevant to the particular deaths under investigation: see Lewis (cited above) at [14]-[19]; Rule 43 Report of Hallett LJ following the London Bombings Inquests, [161]; Chief Coroner’s Guidance No. 5, [17]. However, it does require that the material in the particular investigation has highlighted general or systemic risks or failures which may recur or continue, with potentially fatal consequences: see R (Francis) v HM Coroner for Inner South London [2013] EWCA Civ 313 at [7]-[8], Davis LJ. (d) A coroner may properly decide not to make a PFD Report on an issue on the basis that he/she is not satisfied that further action is necessary. If, for example, it appears that a risk or issue has been addressed by action of some kind, or if circumstances have changed substantially since the death in question, the coroner may reasonably say he/she is not satisfied further action is required. Equally, a coroner may decide that he/she simply has insufficient material to form a view that there are particular risks of future deaths and/or that further action is required. See, for example, the approach taken by Hallett LJ to various issues in her Rule 43 Report after the London Bombings Inquests (e.g. [70] and [217]). See also Jervis on Coroners (13th ed.) at [13-125]. (e) The purpose of death investigation in both domestic law and the law of the European Convention on Human Rights includes a concern to identify systemic failures and risks. See, for example R (Amin) v SSHD [2004] 1 AC 653 at [31]; R (Sacker) v West Yorkshire Coroner [2004] 1 WLR 796 at [11]. The domestic law scheme deliberately confers on a professional adjudicator (the coroner) the judgment whether such risks exist and whether they need to be addressed by action: see Lewis (cited above) at [40]; R (Middleton) v West Somerset Coroner [2004] 2 AC 182 at [38]. 23. Chief Coroner’s Guidance No. 5 also addresses PFD Reports. As that document explains: 7

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2019-0332

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0