Recent Prevention of Future Death Report Highlights the Importance of Internal Investigations

On 20 May 2025, a Prevention of Future Deaths Report (PFD) was made by the Coroner in Birmingham and Solihull Coroner's Court following a suicide conclusion in respect of the death of a Fire Service Chief Officer.

The PFD

The PFD was made in accordance with the Coroner’s statutory duty, which is triggered when a Coroner believes that action should be taken to prevent a future death. In her PFD, the Coroner had two main areas of concern. 

1. The West Midlands First Service (WMFS) did not undertake any investigation after the death and the organisation did not have any policy in place which required them to do so. 
2. The opportunity to learn from a death, such as a suicide that is related to work and welfare support, was not addressed by WMFS and therefore, this creates a risk of future deaths.

Why is this PFD important?

The importance of this PFD for organisations, no matter what your business, cannot be underestimated. 

Not only does the PFD address how important it is that organisations carry out objective and holistic internal investigations following an unexpected death, but it highlights the need for organisations to show that any learnings have been identified and action taken to implement those learnings.  

The PFD also exemplifies the requirement for organisations to have effective policies and procedures in place which minimise the risk of future unexpected deaths, which in this case related to staff welfare policies.

Who undertakes the investigation and whether anticipated legal proceedings need to be borne in mind when undertaking the review will depend on the specific scenario, but what is clear is that organisations must take every opportunity to learn from tragic situations. 

Should you need any advice in respect of the above or inquests generally, please do not hesitate to get in touch.