What Does The ‘Regulation 28, Prevention Of Future Death Report For B. Murray’ Tell Us About The Coroners Service?
(Please refer to PFD Of 2 May 2019 Ref: 10743)
Family and friends were devastated by the suicide of our son Ben in May 2018. He was a ‘fresher’ at Bristol University and just 8 months into his course he took his own life – one of 14 students to do so at that institution in a 2 year period.
At Ben’s funeral, the tribute included the sentiment that we would ‘learn from his life’. For this reason, I could have ‘punched the air’ after Ben’s inquest when Maria Voisin, Avon Coroner, announced her decision to write a Regulation 28 Prevention of Future Deaths (PFD) notice, one that would hopefully bring sector-wide change to Higher Education in the UK.
My reaction to the PFD was very positive for 2 reasons:
Two years on from Ben’s death what has changed? Has anything changed? How would we know? How would the Coroner know? The answer seems to be nobody really knows. Responses were filed within the 60-day deadline but there is no follow-up on the actions therein being completed. Looking at the list of people to whom the Coroner wrote including Universities UK, the Department For Education and Minister For Suicide Prevention, they are no longer in post.
In my opinion, the tragedies will continue unless and until we learn from the past. I think the three biggest contributions this review of the Coroner’s service could make are as follows:
It may be that a change in the law is required to provide the capacity for enforcement or regulating of Section 28 reports. Such a change - together with ‘serious incident reviews’ becoming standard practice - would surely save lives.
 Bereaved parents have helped the NHS and saved lives through the ‘Learn From The Past’ initiative. Some of the resources might be voluntary and I for one would be happy to help.