Claimant death scandal: Chief coroner is failing in duty to prevent future deaths

Chief Coroner: Judge Peter Thornton.

Chief Coroner: Judge Peter Thornton.

Apparently Judge Peter Thornton, Chief Coroner of England and Wales, has insisted that he cannot take any action or issue any advice to coroners on whether they should issue PFD – that’s ‘Prevention of Future Deaths’ – reports after inquests into the deaths of current or former benefit claimants.

He reckons “coroners are independent and the decision to issue a PFD report is for them, depending on evidence they hear”.

How very interesting.

And what a shame that information on his own website makes it clear that this claim is utterly untrue.  His duties include providing “support, leadership and guidance for coroners in England and Wales”.

This includes overseeing the implementation of the new provisions of the Coroners and Justice Act 2009. Among those new provisions is schedule five, paragraph seven, which describes coroners’ duties to complete PFD reports.

As new information continues to be revealed regarding the death of Michael O’Sullivan (‘Mr A’ in this report) – and facts about other deaths related to the DWP, but about which PFD reports were not filed, start to come to light – it seems clear that this gentleman should be encouraged to follow his own rules.

His address is 11th Floor – Thomas More Building, Royal Courts of Justice, London WC2A 2LL, if you want to write a letter to him. Alternatively, email: [email protected]

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11 thoughts on “Claimant death scandal: Chief coroner is failing in duty to prevent future deaths

  1. Mr.Angry

    How very interesting, a contradiction of terms if ever I have heard one. This man does have a legal duty and should implement it forthwith.

    I for one will certainly draft a letter to him within the short term.

    One wonders who is putting pressure on him to make such a vague statement.

    DWP purportedly.

  2. Steve Davis

    I suspect it is another example of only following orders, but it is a shame judges aren’t independent; oh they are because that’s what he said, so any blame for future deaths as well as past ones can be directed in his direction.

  3. Nick

    The legal redress in the uk is very bad the same as any middle eastern country even if you had the money to take out a court action you would still fail against the government such are the odds

    and whats worse most lawyers cant even deal with anything DWP related as they have never been exposed to the DWP laws and have been too lazy to even get involved as there is no money in it for them

    most shameful we were at one time in history a world leader in justice but as i say no more those days are well and truly over

  4. Dez

    Another alleged public servant who cannot comprehend what his actual job is ie making sure any systems that can cause death are fully investigated and immediately escalated to prevent any future deaths from the same cause. Whilst I appreciate this guy is hoping that his inactivity, in keeping pressure off his Government masters’ back, will no doubt earn him him a knighthood, or some ego boosting accolade for services rendered, meanwhile members of the real world are dying! My basic instinct, for such biased incompetence, would be to remove him from this key post and let a human replace him. There are still too many blinkered civil servants and government workers who have totally forgotten what their duties are as public servants…….and should be accountable.

      1. Phil Lee

        Yes – his resignation would only allow the regime to appoint another yes man, who would be just as bad. Better that he stops “just following orders” and does the job as described by his own department, and with the independence of government interference that he is obliged to show, both morally and legally.
        His present behaviour is best summed up by the term “conspiracy to pervert the course of justice”.

  5. Peter Lawless

    My question to him on his resignation was merely a prod, a shot across the bow. Cannot see him responding or rectifying the situation.

  6. Peter Lawless

    For information, I did get a reply,

    Thank you for your email of 24 October.


    The power to issue a Prevention of Future Death Report, in relation to any type of death, lies solely with the coroner who has conduct of the relevant case. A coroner’s duty to issue a report arises where the conditions of paragraph 7(1) of Schedule 5 to the Coroners and Justice Act 2009 are satisfied. For ease of reference, paragraph 7(1) is copied below:


    7(1)        Where—


    (a) a senior coroner has been conducting an investigation under this Part into a person’s death,


    (b) anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and


    (c) in the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances,


    the coroner must report the matter to a person who the coroner believes may have power to take such action.


    Although there is a duty to report provided the three conditions above are met, the third condition is based on a subjective analysis of the situation that can only be made by the coroner who has been conducting the investigation. This position is maintained in the Chief Coroner’s Guidance No.5: Reports to Prevent Future Deaths, which states at paragraph 8, ‘It is for each coroner to decide on a case by case basis whether he or she has a statutory duty to make a report.’ A copy of Guidance No.5 can be found on the Courts and Tribunals Judiciary website via the link below:



    The Chief Coroner has no statutory power to intervene in the decisions of an individual coroner made in the exercise of his/her judicial duties.  This includes a coroner’s decision as to whether or not to issue a Prevention of Future Death Report. Where a person wishes to challenge an individual coroner’s judicial decision this may be done by way of an application to the High Court for judicial review (please note that applications must normally be made no later than three months after the relevant grounds first arose). This is the proper mechanism by which interested parties and members of the public can be assured that the judicial decision making process remains independent and is not subject to improper influence or external pressures. It is in this context that the Chief Coroner is not permitted to compel coroners to complete Prevention of Future Death Reports under any circumstances.


    Yours sincerely


    Rebecca Bland

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