Tracking preventable deaths in January 2025

Welcome to the first monthly review of 2025

The start of 2025 has been huge, and not just at the Preventable Deaths Tracker headquarters. The UK Prime Minister, Sir Keir Stammer, set out a “blueprint to turbocharge AI” on 13 January 2025, taking forward all 50 recommendations from Matt Clifford’s AI Opportunities Action Plan - if only recommendations from other inquiries, like The Coroner Service and the Grenfell Tower Inquiry, were acted on with such haste and resounding support.

The AI announcement came the same week as the series of articles were published in The Times on the need to transform the death investigation system. I was asked in several radio interviews that week whether I thought this news on AI could help the coroner service… My thoughts?

A manifesto for preventing future deaths

The Coroner Service in England and Wales is in such a crisis that jumping straight to AI will not solve its problems for now. However, collaborating with tech firms may be one (of many) ways to generate funding for work like the Preventable Deaths Tracker, as the Ministry in charge cannot seem to do the bare necessities—i.e., respond to coroners' PFDs.

Non-responses

On January 9, the Chief Coroner’s Office published a list of “non-responses” to coroners’ PFDs for reports with responses due between 1 January 2024 and 13 December 2024. While this is a positive step forward, I have some reservations after conducting a thorough analysis of this list. My findings:

• The Chief Coroner’s Office reported 60 PFDs as having overdue responses. This represents 9% of all reports published during this time.

• These 60 PFDs were awaiting 78 responses from 57 organisations.

• According to the Chief Coroner’s Office, the Ministry in charge has the most responses overdue.

Since the Chief Coroner’s Office posted this list, 33 responses (42%) were published on the Judiciary website. So, it works, but not for everyone.

Two-thirds of the PFDs listed (36 reports) still have 45 responses overdue that were sent to 33 organisations. The Ministry in charge remains the worst offender.

While I applaud the Chief Coroner’s Office for finally taking this much-needed initiative, I identified several issues, and my concerns about the PFD ‘system’ remain:

1. Opaque: The list is static, so it’s not easy to summarise this information and collectively see who has not responded and when changes occur.

2. Inefficient: To create this list, the Chief Coroner’s Office sent yet another series of emails to each of the 77 Coroner Areas to ask which reports had not received responses. This takes time, involves manual labour, is prone to errors, and may be obsolete by the time of publication. The reliance on emails and lack of any tracking mechanisms means that the 60 PFDs reported by the Chief Coroner’s Office are likely an underestimate. Information always goes missing in inboxes.

3. Inconsistent: There is no standardisation of the naming of addressees, making it difficult for everyone to use this list. Variations such as “Barts Health Foundation Trust” and “Barts Health NHS Foundation Trust”, neither of which are the true name of “Barts Health NHS Trust”, make it nearly impossible (and extremely time-consuming) to analyse. There are also variable uses of acronyms (e.g. NICE, HMPPS), formatting conventions (e.g. & vs. and), and outright errors. Such issues may seem trivial, but if the basics are inaccurate, how can we trust the rest?

4. Obsolete: The Chief Coroner’s Office plans to manually update this list every six months. The Preventable Deaths Tracker automatically updates every. single. day. 

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On January 22, the Rt Hon. Jeremy Hunt MP invited me to address the All-Party Parliamentary Group (APPG) on Patient Safety. I shared the work of the Preventable Deaths Tracker, which Hunt summarised in the Patient Safety Watch Newsletter. On the same day, I attended the Gambling with Lives Annual Parliamentary Forum and was invited to the APPG on Eating Disorders. The Preventable Deaths Tracker's work transcends all aspects of public life, yet it continues to remain unfunded.

On January 24, the Chief Coroner published the “Guidance for Coroners on the Bench,” often referred to as the “Bench Book.” This resource acts as a central repository of practical information and key principles issued to promote consistency and encourage best practices of coroners. I was delighted to see the Preventable Deaths Tracker recognised in the Guidance and to read the Chief Coroner’s encouragement to use the Bench Book as an online resource, discouraging its printing. Hopefully, this is a sign of more digital and dynamic workflows to come.

Our research on deaths in people with Autism was published in the Journal of Adult Protection in January, which has now become free to download. Rachel’s Voice, a legal programme run by Fieldfisher in collaboration with Mencap, funded this research. Dr David Baker and Dana Norris from the University of Liverpool led this work, and I was funded to identify the PFDs and quantitatively analyse the data. Comms at King’s College London have written a brilliant summary of this research.

Now, on to the January statistics and a bonus analysis of “non-responses” to PFDs using the Preventable Deaths Tracker’s new interactive dashboard.