

How can avoidable deaths be prevented?
6 snips Jun 11, 2025
Deborah Coles, director of Inquest, and Alexander Learmonth, a King's Counsel, delve into the stark realities of state-related deaths. They discuss the lack of accountability in implementing coroner recommendations and the urgent need for a national oversight mechanism, citing tragic instances like Grenfell. The conversation also touches on recent legal reforms around wills and a landmark divorce case that reshapes asset distribution. Together, they uncover the complexities of law and humanity in the fight for safety and justice.
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Coroners' Warnings Lack Teeth
- Coroners can issue Prevention of Future Deaths (PFD) reports but lack enforcement powers.
- That gap means many recommendations are ignored and opportunities to save lives are missed.
PFD Use Rises But Responses Often Hollow
- Usage of PFDs is rising (713 in 2024) but many responses are template replies.
- Families face distress and re-traumatisation when repeated failures occur without clear follow-up.
Amina Ismail Case Highlights System Failures
- Amina Ismail died in a psychiatric intensive care unit after prolonged detention due to bed shortages.
- The coroner's PFD highlighted underfunding, over-reliance on private providers, scarce specialist units, and flawed funding for rehab.