Analysis of ‘Prevention of Future Deaths’ Reports

Background

Learning disabled people have a shorter life expectancy and increased risk of early death compared to the general population. When learning disabled people die early, they are less likely to have an inquest (an investigation) held about their deaths. We need to understand what can be done to stop people dying.  

If an inquest is held into someone’s death, and a coroner (the investigator) believes there is a risk of future deaths, they have a legal duty to issue a Prevention of Future Deaths (PFD) Report. These are sent to the person or organisation the coroner believes can take action to reduce or remove the risk.  

• What this project will explore (and how)

  This project will add to the social care evidence base about learning disabled people’s lives and deaths.

  It will: 

  • Collect together all the PFD reports issued following the deaths of learning disabled people since 2013 

  • Look at what PFD reports say about the lives and deaths of learning disabled people  

  • Explore the language used by coroners and what they say about learning disabled people, carers, family members, social care services, health provision, mental capacity law and other key themes 

  • Understand what concerns coroners highlight that need addressing to prevent other people dying  

  • Identify learning for those working in social care and health services from the reports 

  • Look at the responses that people share when they are sent a PFD
  • Ask national organisations how they currently learn from PFD reports

  • Work with the public and practitioners to understand their priorities and the most useful ways to share the learning from the project 

  • Produce outputs to share what needs to happen to improve social care and health practice to stop people dying 

  • Work with learning disabled people and bereaved relatives to ensure key learning is shared far and wide. 

• Planned outputs and outcomes

  By the end of this project, we will have: 

  • A greater understanding of what change needs to happen to stop learning disabled people dying premature and preventable deaths 

  • Created outputs that share findings for different groups  

  • Co-produced plans to ensure people who need to know, are aware of the project findings (and PFDs) and use them to try to stop people dying 

  • A draft academic journal article and/or book chapter

  • Easy Read and/or Accessible summaries of the project findings.