Thank you for your article on how coroners’ prevention of future deaths (PFD) reports are being routinely ignored (Coroners’ advice on maternal deaths in England and Wales routinely ignored, study finds, 19 November).
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.
The trust resisted, claiming that, being non-verbal, Juliet was hard to treat. Would there have been any improvements without the PFD? We were dismayed to find that there was no legal enforcement of the promised measures.
People with learning disabilities are over three times more likely to die from treatable causes (avoidable by proper healthcare) than the general population. The avoidable death rate is nearly double. Having seen how the NHS protects itself, rather than vulnerable patients, we wholeheartedly believe that PFDs should be legally enforced.
We want no one else to die as Juliet did, nor for any other parent to suffer the same grief. That her death could have been avoided adds extra cruelty. We share this with all victims of healthcare scandals.
Christine and Francis Saunders
Romford, Essex
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