Prevention Of Future Death Reports In Relation To Young People With Autism

Topics covered: autism, CQC, dhsc, inquests, pfd report

The BBC has carried out an investigation into the care provided to young people with Autism. As part of this, the BBC reviewed over 4,000 Prevention of Future Death (“PFD”) reports delivered in England and Wales over the past 10 years.

The investigation identified that the Coroner had issued PDF reports in 51 cases which described serious failings in the care of autistic people. The majority of those who died were under the age of 30 years old of those people and some of them were children.

The causes of death concluded by the Coroner in the inquests varied but nearly half were categorised by Coroners as relating to mental health or suicide. The BBC’s research identified five key concerns which had been raised by coroners over the past decade. They were:

  1. A lack of trained staff with an understanding of Autism
  2. Failure to treat Autism and mental health problems as two separate conditions
  3. Shortage of specialised accommodation
  4. Lack of a health professional to co-ordinate the young person’s care – as recommended in NICE guidelines.
  5. Late diagnosis of Autism

Former Justice Secretary Sir Robert Buckland who heads the all-party parliamentary group on Autism, described the BBC’s findings as, “deeply disturbing” and called for the government to investigate urgently. He said, “Lessons are not being learned. Fifty-one [deaths] is a lot. It suggests a systemic problem” and, What is the point of PFDs if there is no accountability?”

Deborah Coles from the charity Inquest shared the same concerns as Sir Robert Buckland and said that reports about, “potentially life-saving recommendations for change” should be treated with the utmost seriousness.

Inquests and PFD Reports

An inquest is a public judicial inquiry into a person’s death and a Coroner is required to investigate a death if there is reasonable cause to suspect that the death was as a result of the following:

  • A violent death
  • An unnatural death
  • The cause of the death is unknown
  • The person died whilst in custody or state detention (Article 2 ECHR)

A Coroner has a duty to issue a PFD report which identifies areas of concern to any person or organisation where, in the opinion of the Coroner, action should be taken to prevent future deaths.  PFD reports are publicly available documents and are often sent to organisations such as the CQC or DHSC so that wider lessons can be learnt.


The team at Ridouts regularly advise providers in relation to inquests, potential risks around PFD reports and how to mitigate against them. If you require assistance or advice in relation to this our specialist solicitors can help.

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