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Preventability
Preventability reports evaluate whether a fatality could have been avoided through different clinical or operational actions. These assessments provide Coroners with an expert opinion on the existence of foreseeable risks and the feasibility of alternative interventions that may have preserved life.
Overview
When this report is required
- Prevention of Future Death (PFD) Reviews occur when a Coroner considers issuing a Regulation 28 report to an organization
- Clinical Omission Inquiries arise when it is alleged that a failure to act led to a fatal outcome
- Suicide Risk Management Assessments are necessary to determine if healthcare providers missed “red flag” indicators or warning signs
- Systemic Escalation Failures involve investigating whether a patient’s clinical deterioration was recognized but not appropriately escalated
What the expert assesses
- Foreseeability of the fatal event
- Reasonableness of the preventive steps taken
- Impact of earlier clinical intervention
- Adherence to national safety guidelines
- Recognition of clinical warning signs
Report specification
| Element | Detail |
|---|---|
| Assessment Setting | Desktop Review, Records Audit, Remote |
| Court Acceptance | Coroner’s Court, Public Inquiry |
| Compliance | CPR Part 35 |
CPR Part 35 Compliant
Digital Delivery
Urgent Instructions
Specialist expertise
Specialist Consultants
Nursing Leads
Patient Safety Experts
While these are the primary specialists engaged for this instruction type, please note that every case turns on
its own facts. Complex or multi-disciplinary cases may require a bespoke team of experts. Our case managers will
review your specific instruction to ensure the correct clinical match.