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Coroners’ PFD reports are not used   [CCO], there are at least 70 PFD reports   FAST FACTS
               frequently enough, and they are rarely   involving accidents at work and health and
               addressed to employers, says Professor   safety-related deaths. There has, however,   UK fatalities
               Sarah Waters at the University of Leeds, co-  been no systematic analysis of these reports.’
               author of the report, Work-related suicide:   CCO guidance states that a coroner   at work
               a qualitative analysis of recent cases with   must send the PFD report to the person or
               recommendations for reform. ‘We studied   organisation who they believe has the power   135  123
               suicide cases where there was strong material   to take remedial action.
               evidence of work-related causality, where no   ‘We often see PFD reports sent to a   in 2022/2023  in 2021/2022
               PFD report was issued following a suicide   parent company, professional association
               death,’ Sarah explains. ‘When PFD reports   or regulatory body, where the concern is   UK industries
               are issued, they are usually addressed to   likely to apply on a wide scale,’ says Ali at   with the highest
               the NHS, prison services and mental health   RWK Goodman. ‘Nonetheless, it is inevitable   deaths
               services – but rarely to employers. Work-  that concerns identified are not always

               related suicide is a blind spot.’  shared with every organisation which might
                 The failure to recognise, monitor and   potentially benefit from knowing about

               regulate work-related suicides poses serious   them.’
               and ongoing risks to the health and safety of   Monitoring and analysis of PFD report data
               UK employees, the report states.   by organisations is not a legal requirement,
                                                                                                      Construction (45)
                 ‘While a PFD report can act as an   and requires a significant investment in terms

               important window on risks to public safety   of resource, explains Ali: ‘PFD reports are
               and a powerful lever for change, these were   publicly available on the Judiciary website
               only produced in 25% of cases and were                                        Agriculture,
                                                                                             forestry and
               only addressed to the employer in two of   PFD reports are                    fishing (21)

               those cases,’ the report notes. ‘In 66.6% of
                                                  a key opportunity

               the cases, the coroner identified work or the
               workplace as a causal factor in the suicide at
               the inquest, yet a PFD report was only sent to  to learn from
               the employer in one of those cases.’  fatalities at work                                  Manufacturing
                 The report also found that coroners’ PFD                                                (15)
               reports are rarely and inconsistently used
               in cases of work-related suicide and as a   [judiciary.uk] – save for rare exceptions – but
               result, opportunities for suicide prevention   the system is rudimentary and sets challenges
               in the workplace are lost: ‘Where a PFD   when seeking to analyse the data for a specific   Transportation

                                                                                             and storage
               report is issued to an employer, this acts as a   theme, such as organisation or injury type.’  (15)
               lever for change that prompts concrete and   According to Georgia, Preventable Deaths
               reportable changes in workplace conditions   Tracker data has supported 25 research
               and practices.’                    studies to examine coroners’ concerns
                 Additionally, a PFD report provides a   and provide real-time analytics to identify   The three most
               documented record of health and safety   important trends in preventable deaths.
               concerns that can be used more widely by   ‘Most notably, when assessing 10 years of   common causes
               regulators. A key recommendation of the   data, we’ve found that about 25% of PFD
               report is that coroners should consistently   reports involved suicides, 18% medicines and   Falls from height (40)
               issue a PFD report to an employer where   12.5% falls.’
               evidence of work-related causality is   Georgia says that with dedicated funding,
                                                                                                   Being struck by a moving
               presented at the inquest.          research using the Preventable Deaths            object (29)
                 ‘Coroners’ PFD reports are underutilised,   Tracker database could be undertaken to
               and often dismissed, by many organisations   identify learnings that safeguard employees   Being struck by a moving
                                                                                                   vehicle (20)
               in the UK,’ says Dr Georgia Richards,   and reduce occupational deaths.
               founder of the Preventable Deaths Tracker.   ‘Showcasing the positive impact that
               ‘According to the Chief Coroner’s Offi  ce   PFD reports can have on improving the   Source: HSE, 2023

                                                                                                             IOSH MAGAZINE 67



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