"Experience has shown us that a coroner's PFD report is issued in response to serious systemic failings and a trust's inaction to prevent future tragedies. Tolerating poor care and refusing to learn seem to be shared features of health scandals, including the treatment of people with learning disabilities, such as our own beloved daughter, Juliet Saunders, who died aged 25."
"She died because the local hospital made a misdiagnosis and discharged her unsafely. The harrowing experience of the inquest was softened for us by the coroner seeing that Juliet was dearly loved and happy. The inquest exposed a series of systemic failings and clinical errors. The coroner rejected the trust's own investigation, finding that neglect had contributed to Juliet's death, and issued a PFD with eight recommendations."
Coroners' prevention of future deaths (PFD) reports are frequently disregarded despite identifying serious systemic failings and institutional inaction. A 25-year-old woman with learning disabilities died after a local hospital misdiagnosed her and discharged her unsafely; the coroner found neglect contributed to her death and issued a PFD with eight recommendations. The trust resisted, arguing non-verbal status complicated treatment, and promised measures lacked legal enforcement. People with learning disabilities face much higher mortality from treatable causes—over three times the risk and nearly double the avoidable death rate. PFDs should carry legal enforcement to prevent repeat tragedies.
Read at www.theguardian.com
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