Coroners’ suppression of future death reports should be legally implemented | NHS

Thank you for your article on how coroners’ advice on maternal deaths in England and Wales is routinely ignored (Study finds coroners’ advice on maternal deaths in England and Wales, 19 November).

Experience has shown us that a coroner’s PFD is issued in response to serious systemic failings and the trust’s failure to prevent future tragedies. Tolerance of poor care and refusal to learn appear to be common features of health scandals, including the treatment of people with learning difficulties, such as our beloved daughter Juliet Saunders, who died aged 25.

She died because the local hospital misdiagnosed her and discharged her unsafely. The horrific inquest experience was softened for us when the coroner saw that Juliet was very loved and happy. The investigation revealed a series of systemic failures and clinical errors. The coroner refused to investigate the private trust, He found that negligence contributed to Juliet’s death, and issued a statement with eight recommendations.

She resisted trusting, claiming that Juliet, being non-verbal, was difficult to treat. Would there have been any improvements without the PFD? We were dismayed to discover that there was no legal implementation of the promised measures.

People with learning difficulties more than three times More likely to die From treatable causes (preventable with proper health care) in the general population. The avoidable mortality rate is Nearly double. Having seen how the NHS protects itself, rather than protecting vulnerable patients, we strongly believe that PFD standards should be legally enforced.

We don’t want anyone else to die the way Juliet did, or for any other parent to experience the same grief. The possibility of avoiding her death adds to the cruelty. We share this with all victims of health care scandals.
Christine and Frances Saunders
Romford, Essex