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Prevention of Future Deaths

The purpose of an inquest is to find answers to the questions the Coroner is required by law to find answers to, namely:

  • who the deceased was; and
  • when and where and how the person came by their death.

Generally, the Coroner is prohibited from commenting on other matters, and from making findings of civil or criminal liability. However, pursuant to Rule 12 of the Inquests and Post-Mortem Examinations (Jersey) Rules 1995,  where the Coroner believes that action should be taken to prevent the recurrence of a fatality that is similar to that in respect of which the inquest is being held, he may make a report to the person or authority who has the power to take action to prevent future deaths. This report is known as a Prevention of Future Death's Report (PFD).

In the table below there is a list of PFD Reports issued from the beginning of 2026, together with the responses that have been received to those PFD Reports. 

Name of deceasedDate of deathDate of inquestDate PFD issuedPFD sent toSummary of Coroner's recommendation(s)Responses received
Elaine Janet McKenna23/07/2521/01/2611/03/26Minister for HealthImplement a fast-track pathway for investigations into cases of suspected cancer.Response from the Chief Officer 
George Michael Monte De Ramos Castrudes23/01/2524/02/2604/03/2026Minister for Home AffairsMinister for EnvironmentPresident of Jersey Farmers Union (JFU)Identify and assess portacabins used as winter staff accommodation for compliance with rented dwelling safety laws.Response from JFU 
Victor Charles Francis Tinley06/01/2519/03/2630/03/26Minister for HealthEnsure integrated access to complete medical records across primary and secondary care.Response from the Chief Officer