Learning disabled people have a shorter life expectancy and increased risk of early death compared to the general population. When learning disabled people die early, they are less likely to have an inquest held about their deaths. If an inquest is held into someone’s death, and a coroner believes there is a risk of future deaths, they have a legal duty to issue a Prevention of Future Deaths (PFD) Report.
These reports are sent to the person or organisation the coroner believes can take action to reduce or remove the risk. To date there has been no research looking at the content of PFD reports issued following the deaths of learning disabled people. Consequently, social care and health services are operating without the benefit of these warnings as PFDs are only directed at specific organisations, not the wider health and social care system.
This exploratory, one year project will:
- Collect together all the PFD reports issued following the deaths of learning disabled people since 2013 and look at what PFD reports say about the lives and deaths of learning disabled people.
- Understand what concerns coroners highlight that need addressing to prevent other people dying and identify learning for those working in social care and health services from the reports.
- Work with learning disabled people and bereaved relatives to ensure key learning is shared far and wide.
- Work with the public and practitioners to understand their priorities and the most useful ways to share the learning from the project and produce outputs to share what needs to happen to improve practice.
The work will be led by Dr George Julian supported by Prof David Abbott at the University of Bristol, Profs Sara Ryan & Chris Hatton at Manchester Metropolitan University in collaboration with learning disabled people, bereaved relatives, social and health care organisations, lawyers and activists. The project will run from Feb 2026 – March 2027.
Dr Julian said: “This very necessary award will allow Prevention of Future Death Reports to be analysed and the warnings and learning within them to be shared with those in social care and health services who can take steps to prevent learning disabled people dying premature and preventable deaths”.