What Does The Regulation 28, Prevention Of Future Death Report For B. MurrayTell Us About The Coroners Service?

(Please refer to PFD Of 2 May 2019 Ref: 10743)

Written evidence from James Murray

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:

  1. The Inquest is a stressful process for all bereaved parents. Will ‘justice’ be done? Will we be left feeling that our children’s deaths were mere statistics? Will this be regarded as just another suicide? In our case, without the available funds for a lawyer we took it upon ourselves to push for answers that might help prevent the same mistakes being made in the future – this is heavy lifting emotionally and intellectually for parents.


  1. The Coroner’s recommendations were powerful and if implemented would surely save lives – this is important to bereaved parents and represents newfound ‘hope’ for the future.

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:

  1. Give the Chief Coroner powers to enforce or compel agencies including government departments, to comply with or show changes implemented as a result of recommendations or actions contained within PFD reports made by coroners.


  1. Mandate that all institutions in which a serious incident such as a suicide has occurred, conduct their own review and root-cause analysis in order to improve safety. In Maria Voisin’s words “such a written report usually affords an opportunity to review what happened; what was done well/the good practice points; areas of concern…and importantly what lessons can be learned...with a formal action plan…Such a document is very helpful to the Coroner when considering and discharging this duty”.


  1. Provide resources[1] to support the Coroner’s service to identify and group types of death by causation, demographic, location or other criteria to help identify patterns from which education facilities, student support services, government departments, health trusts, police forces, regulatory bodies and other agencies can learn.

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.


[1] 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.