RWK Goodman - May Bulletin
Learning from Loss: A Comparative Analysis of Prevention of Future Death Reports in Adult Social Care (Jan–May 2024 vs. Jan–May 2025)
So far this year, there has been a notable shift in in the issuance of Prevention of Future deaths reports (PFDs), particularly in relation to care homes and community. When compared to the same period in 2024, there is a discernible increase in both the number and scope of these reports – highlighting the systemic pressures and the desperate need for reform in adult social care services.
Role of PFD reports
PFD reports are issued by coroners in situations where the coroner feels that action could and should be taken to prevent future deaths. The reports are intended to highlight circumstances to relevant organisations and urge them to take corrective actions.
The reports are published online and are available for anyone to read.
Statistical Overview: A Year-on-Year Comparison
Recent figures confirm that the number of deaths reported to the Coroner in 2024 were the lowest since 1995 – and down 10% as compared to 2023. Despite this reduction in deaths reported to the coroner and a drop in the number of inquests opened by 1%, the number of PFD’s issued surged by 25%, with 713 being issued in 2024.
Of those 713 reports, 34 were linked to care homes and 20 to community health care and emergency services, highlighting persistent vulnerabilities in these settings.
So far in 2025 (up to 12 May 2025), 210 PFDs have been issued – down from 242 in the same period in 2024. However, those related to care homes and community care have doubled – from 11 this time last year to 22 in 2025, suggesting a heightened scrutiny of adult social care.
Key Themes Emerging from PFD Reports
An analysis of recent PFD reports reveals recurring themes that warrant attention:
1. Inadequate investigation – a number of PFD reports have identified that internal investigations in many cases were inadequate and were carried out by people who had not received sufficient training to carry out such functions.
2. Policy failure and poor governance – outdated or unclear policies were noted in a number of cases with lack of effective pre admission assessments or care plans being specifically mentioned. A number of reports identified that serious incidents did not trigger a policy based review and that in some cases falls were not adequately monitored or reported.
3. Inadequate training – specifically in emergency response and life training proceedings, as well as in carrying out investigations. One case highlighted the lack of awareness of anti-choking devices.
4. Poor communication and record keeping – a number of cases raised concerns with poor continuity of medical information (leading to medication errors), lack of records and lost or inconsistent records
Implications for Adult Social Care Providers
The rising number of Prevention of Future Death (PFD) reports highlights the need for adult social care providers to take proactive steps in addressing systemic failings. These reports not only underscore areas requiring urgent improvement but also reflect the broader pressures facing the sector, including workforce shortages, funding constraints, and increasing care complexity. In response, providers should consider the following key measures:
Improving Communication Protocols: Establishing clear, consistent communication pathways between care staff, families, and healthcare professionals to ensure coordinated and person-centred care.
Prioritising Workforce Development and Retention: Investing in ongoing training, career development, and fostering supportive working conditions to attract and retain skilled staff—an increasingly difficult task amid high vacancy rates and burnout.
Enhancing Discharge Planning Processes: Strengthening partnerships with hospitals and community services to ensure patient discharges are safe, well-timed, and supported—especially crucial given the challenges in managing complex needs post-discharge.
Embedding Quality Assurance and Monitoring: Introducing or reinforcing internal audit systems to regularly evaluate care quality, identify risks, and ensure compliance with established standards.
While these actions are critical, they must be supported by broader policy and funding reforms to address the systemic challenges that continue to strain adult social care services across the UK.
RWK Goodman’s expert Health and Social Care Team provides support to health and social care provides including care homes, supported accommodation providers, domestic care agencies and children’s services.