Bereaved parents Christine and Francis Saunders are calling for a critical reform in the coroner’s role to ensure that warnings issued after inquests into preventable deaths carry legal force. In an open letter published in The Guardian, the couple highlights the urgent need for systemic change to prevent future deaths, particularly those of vulnerable individuals like their daughter, Juliet Saunders.
Juliet’s tragic death, exacerbated by neglect and systemic failures within a healthcare trust, was thoroughly investigated by a coroner who found that crucial preventative actions had not been taken. Despite this, the recommendations issued in a Prevention of Future Deaths (PFD) report have not been enforced, leaving the Saunders family uncertain about whether any improvements were implemented to prevent similar tragedies in the future.
“We cannot know if the recommendations made by the coroner were ever acted upon,” said Christine Saunders. “It’s heartbreaking to think that, even with clear findings of neglect and failings, there is no legal obligation for those responsible to take immediate corrective action.”
The couple’s call comes in the wake of a nationwide issue where 25% of deaths involving people with learning disabilities—compared to 36% of the general population—are referred to a coroner. Moreover, the NHS program designed to reduce avoidable deaths does not record PFD reports, making it nearly impossible to track whether recommendations for future deaths are being implemented.
A 2013 confidential inquiry into premature deaths among people with learning disabilities (CIPOLD) found that valuable information in reports is often “locked away” and at risk of being ignored. The Saunders family fear that the same fate could befall PFDs unless reform is enacted to give them the force of law.
“We were dismayed to discover there was no enforcement of the PFD recommendations,” said Francis Saunders. “Even when a Care Quality Commission inspector noted the necessary measures were in place, they were never mentioned in the final inspection report, leaving us in the dark about whether those changes were actually made.”
The Saunders family are also drawing attention to the broader implications for adults with acquired brain injury (ABI), highlighting another area where safeguarding adults reviews (SARs) have failed to prevent deaths. Reports like those of “Tom” from Somerset and “James” from Brighton reveal systemic failings in health and social care services that have allowed preventable deaths to occur among individuals with ABI. These tragic cases often reflect a pattern of mismanagement and inadequate support that leaves vulnerable adults without the care they desperately need.
Christine Saunders concluded: “The stories of Tom and James echo the pattern of neglect and underfunding in health and social care. How many more people will suffer and die needlessly before there is adequate action to improve these services?”
The Saunders family’s call for reform is an urgent plea to policymakers and the public to take a stand. They are advocating for legal accountability in the enforcement of coroner’s warnings and safeguarding reviews, urging that no more lives should be lost due to avoidable failings.
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