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 deceased	Date of death	Date of inquest	Date PFD issued	PFD sent to	Summary of Coroner's recommendation(s)	Responses received
Elaine Janet McKenna	23/07/25	21/01/26	11/03/26	Minister for Health	Implement a fast-track pathway for investigations into cases of suspected cancer.	Response from the Chief Officer
George Michael Monte De Ramos Castrudes	23/01/25	24/02/26	04/03/2026	Minister for Home Affairs; Minister for Environment; President 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 Tinley	06/01/25	19/03/26	30/03/26	Minister for Health	Ensure integrated access to complete medical records across primary and secondary care.	Response from the Chief Officer
Susan Jane Brizell	17/11/25	26/08/26	21/09/26	Minister For Health	Address absence of a formal process through which families and carers can raise concerns about clinical deterioration.	Initial acknowledgement received from the Minister noting that consideration is being given to the issue raised.
David Keith Morgan	04/08/25	13/10/26	19/10/26	Minister For Health	Provide safeguards on the prescribing of cannabis based products for medicinal use (CBPMs) and support better partnership working between agencies.