Publication alone can’t guarantee wider learning from student deaths

Prevention of Future Deaths reports, or PFDs, are a statutory mechanism through which coroners raise concerns identified during an investigation with a view to preventing future deaths.

A new parliamentary answer about their use raises an important question for higher education.

If government expects departments, regulators, and other bodies to turn coroners’ concerns into wider learning, how is that learning shared when a student death gives rise to a PFD?

Only the starting point

Where an investigation reveals circumstances creating a risk of future deaths and the coroner considers that action should be taken, the coroner has a statutory duty to issue a report to a person or organisation that may have the power to act. Reports and responses are generally published.

On 18 September, the Ministry of Justice set out its position on PFD reports. The government says publication is intended to allow coroners’ concerns to be “understood, analysed and utilised” by recipients and other interested organisations. But publication isn’t, by itself, a learning system.

The Ministry of Justice doesn’t centrally assess or monitor action arising from individual PFDs, and currently has no plans for a national learning-from-deaths strategy. Instead, it points to bodies with their own expertise, statutory functions, and mechanisms for learning.

The example it gives is instructive – the Department of Health and Social Care tracks relevant PFDs and makes regulators and other bodies aware of concerns so that recurrent themes and risks can be considered and acted upon.

Existing coronial guidance already recognises that an issue may extend beyond the organisation immediately involved. Where a concern is wider or national, directing a report to a national, professional, or regulatory body may enable wider preventative action. The guidance goes further in some sectors – coroners are advised, for example, routinely to send relevant PFDs to bodies including the Department of Health and Social Care so that wider lessons can be learned.

Writing to the Chief Coroner

In August, I wrote to the Chief Coroner about what that established principle might mean in higher education. I asked whether, where a student death PFD raises concerns capable of wider application, coroners might be encouraged to consider whether an appropriate sector-level body should also receive it. I wasn’t proposing law reform, but an enhancement of existing practice.

The Chief Coroner confirmed that decisions about recipients remain matters for individual coroners. I was, however, asked for permission for the content of my letter and the issues raised to be shared in the Chief Coroner’s next round of correspondence with coroners. That doesn’t amount to changed coronial practice, but it does place the possible application of that existing discretion in higher education more clearly into the wider conversation.

Connecting wider learning

There’s already evidence that the Department for Education has considered PFDs. In February, it told Parliament that they form part of the evidence considered when examining variation in how providers support students at risk of harm.

But considering published reports is different from having a defined mechanism through which concerns arising from one death are identified, connected to wider patterns, and shared with a body able to consider their significance across a sector.

The health example is useful, but it can’t simply be transposed into higher education. The NHS is expressly described as an integrated system of organisations and services and a national service for which government sets the framework and is accountable to Parliament.

English universities are differently constituted. They’re autonomous, independently governed institutions operating in a system where competition between providers is expressly recognised within the regulatory framework. The relationship between government and individual providers is therefore different.

The Office for Students might seem the obvious place to look. But it says explicitly that it doesn’t directly regulate providers specifically on suicide prevention, and has no role in investigating individual cases of suspected or confirmed student suicide. Related issues may engage its wider conditions of registration, but there’s no general welfare condition equivalent to the one that now exists in Wales.

A clearer pathway in Wales

From 1 August 2026, Medr’s Staff and Learner Welfare condition applies as an initial and ongoing condition of registration. It requires providers to have effective arrangements to support and promote staff and learner welfare.

Its supplementary requirements include ongoing self-evaluation of welfare arrangements and risks, and the submission of a two-year welfare action plan. Medr says those plans will inform its engagement with individual providers and help identify sector-wide support needs and systemic risks and issues.

Its 2026–27 wellbeing and mental health funding guidance reinforces that approach, expecting providers to maintain ongoing dialogue with Medr, raise emerging issues, and share learning and practice in support of “timely intervention, shared learning, and continuous improvement across the sector.”

This doesn’t give Medr a function of collecting or disseminating PFDs, nor does it mean that it should investigate individual deaths. The point is narrower. Where a coroner identifies a welfare concern with potential relevance beyond one institution, in my view Medr’s regulatory remit gives it an identifiable interest in that wider learning.

Beyond the individual report

Whether that learning is directed to the regulator through the PFD process depends, at least in part, on coroners recognising its potential sector-wide significance and exercising their discretion to include an appropriate sector-level body among the recipients. There’s no guarantee that this will happen.

But the issues raised in my letter are to be shared in the Chief Coroner’s next round of correspondence with coroners across England and Wales, raising awareness of that possibility across the coronial system.

In Wales, then, the pathway for wider learning is becoming easier to see.

But wider learning can’t stop at the border. The coronial system operates across England and Wales, while higher education is regulated through different national arrangements as a consequence of devolution.

A concern identified through a student PFD may have relevance to providers on either side of that divide. If wider learning is to fulfil its preventative purpose, it must be capable of crossing regulatory as well as institutional boundaries.

Crossing the border

The government’s answer makes clear that publication is only one part of the process. In health, somebody tracks the reports, connects concerns, and gets information to bodies capable of considering what action may be required.

Publication alone can’t guarantee wider learning. It can make learning available, but availability doesn’t create a route by which that learning is identified, connected, and shared.

If PFDs are intended not simply to record concerns but to help prevent future deaths, important learning must be capable of travelling beyond the institution named on the first page, and across the borders between the systems that regulate them.

Wales may now offer a more visible route for welfare-related learning, but that route can’t end at the border.

So what should the roadmap for wider learning from student PFDs look like across higher education in England and Wales?