Grieving Parents Demand Legal Force for Coroners' Warnings
A couple from Romford, Essex, whose daughter died due to hospital failings, has joined calls for coroners' prevention of future deaths (PFD) reports to be made legally enforceable. This comes after a recent study exposed that such crucial advice, particularly concerning maternal deaths in England and Wales, is being routinely ignored by NHS trusts.
A Preventable Tragedy and a System's Failure
Christine and Francis Saunders lost their beloved 25-year-old daughter, Juliet, after a local hospital made a misdiagnosis and discharged her unsafely. An inquest into her death revealed a series of systemic failings and clinical errors. The coroner rejected the trust's own internal investigation, formally found that neglect had contributed to Juliet's death, and issued a PFD report containing eight specific recommendations for improvement.
The trust resisted the findings, reportedly claiming that Juliet, who was non-verbal, was hard to treat. Her parents were left questioning whether any safety improvements would have been made at all without the coroner's intervention.
A Pattern of Ignoring Lessons and Tolerating Poor Care
The Saunders' harrowing experience reflects a broader, alarming pattern within the healthcare system. They state that "tolerating poor care and refusing to learn seem to be shared features of health scandals." Their dismay was compounded when they discovered that the promised measures from the PFD report lacked any legal enforcement, leaving the trust with no formal obligation to act.
This issue has devastating consequences. People with learning disabilities are over three times more likely to die from treatable causes than the general population, with the avoidable death rate being nearly double. The Saunders family, having witnessed how the NHS can sometimes protect itself over vulnerable patients, now wholeheartedly believes that PFDs must be given the force of law.
Their motivation is simple yet profound: they want no other family to suffer the same grief. The added cruelty, they share with all victims of healthcare scandals, is the knowledge that Juliet's death was entirely avoidable.
