Chief coroner’s new ‘badge of dishonour’ for failing organisations – could this save lives?

Organisations are being named and shamed for not responding to coroners’ recommendations to prevent future deaths. But does this go far enough to hold them to account, or do we need more punitive sanctions?

Bolt Burdon Kemp has long been raising concerns about the huge backlog of inquests, which also means that publication of Prevention of Future Death (PFD) reports are delayed.

Last year, we made submissions to the Justice Committee’s follow-up inquiry into the coronial service, providing insight into our experiences supporting clients through inquest proceedings. We said these hold ups – and the subsequent delays to Prevention of Future Death (PFD) reports could cause more needless deaths.

PFD reports are issued by the coroner to identify lessons that could be learnt to prevent others from losing their lives in similar circumstances. Any time lag in the publication means an inevitable risk that further lives could be lost in the same way in the intervening period.

The danger to life is further amplified when a serious risk to life is discovered but recipients of a PFD report then fail to take action to protect lives.

In recent years there has been increasing criticism that the PFD reporting system is not fit for purpose. Deborah Coles of charity Inquest has confirmed that the reports “are simply not being used in a way that can help protect lives”.

Responding to a PFD report is an opportunity for an organisation or institution to demonstrate commitment to improving safety standards and to re-build lost confidence where failings were found to have contributed to a fatality.

An organisation in receipt of a PFD report should provide a response to the coroner within 56 days. However, it is reported that from July 2013 to date just 47.8% of reports issued have received a full published response.

A potential reason for the lack of compliance is the absence of legislation in providing a coroner with any enforcement power to compel a response to a PFD report. But this situation is now evolving with the introduction of a new mechanism which could well encourage increased compliance with PFD responding.

New policy

On 1st January 2025, the chief coroner for England and Wales, Her Honour Judge Alexia Durran, introduced a new policy to effectively name and shame institutions/organisations who fail to respond to PFD reports within the 56-day timeframe.

Under the new policy, the chief coroner publicly lists organisations on the Courts and Tribunals Judiciary website that do not respond to PFD reports within the requisite timeframe. The chief coroner describes featuring on this list as a “badge of dishonour”.

It is hoped the reputational risk associated with appearing on this public list will in turn deter organisations and/or institutions from failing to respond to a PFD report which has potential to save lives.

It is apparent those administered a badge of dishonour are likely to incur increased public scrutiny where failings occur following inaction.

Conclusion

When lives are lost in recurrently similar circumstances, despite the existence of a PFD report recommending the implementation of improved safety standards, there will undoubtedly be scepticism of the effectiveness of the PFD process.

In addition, it is perfectly plausible that coroners themselves may be increasingly frustrated with lessons not being learnt from the PFD reports they are issuing but not able to enforce.

Certainly, the chief coroner’s latest initiative to name and shame organisations which fail to respond to PFD reports is a step in the right direction. It seems to represent a more robust approach to non-compliance and allows for increased public scrutiny.

This shift in a reduced tolerance of non-compliance may help to restore faith in the PFD system. However, coroners are still without enforcement powers which could help to ensure those who have wronged implement necessary changes to ensure their practices and procedures evolve.

Some organisations may be less concerned with reputational damage than others and punitive sanctions may be a more effective tool for ensuring compliance.