Page 67 - IOSH JanFeb24_Full LR

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

64-68 Preventing future deaths_Jan-Feb 2024_IOSH.indd 67 13/12/2023 09:18