Thanks for your article on how coroners' Prevent Future Deaths (PFD) reports are routinely ignored (Coroners' recommendations on maternal deaths in England and Wales routinely ignored, study says, 19 November).
Experience has shown us that the Coroner's PFD report is published in response to serious system failures and the trust's failure to act to prevent future tragedies. Toleration of poor care and refusal to learn seem to be common features of health care scandals, including the treatment of people with learning disabilities such as our beloved daughter, Juliet Saunderswho died at the age of 25.
She died because the local hospital misdiagnosed her and discharged her unsafely. The painful experience of the investigation was softened for us by the fact that the coroner saw that Juliet was dearly loved and happy. The investigation revealed a number of systemic deficiencies and clinical errors. The coroner rejected the trust's own investigation. finding that neglect contributed to Juliet's death and issued a PFD with eight recommendations.
The trust resisted, arguing that because Juliet was taciturn, she was difficult to handle. Would there be any improvement without the PFD? We were dismayed to discover that the promised measures were not backed by any legal backing.
People with learning disabilities more than triple more likely to die for treatable causes (that can be avoided with proper medical care) than in the general population. Preventable deaths are almost doubled. Having seen how the NHS protects itself rather than vulnerable patients, we truly believe PFDs should be enshrined in law.
We want to ensure that no one else dies the way Juliet did and that no other parent suffers the same grief. The fact that her death could have been avoided adds even more cruelty. We share this with all victims of healthcare scandals.
Christina and Frances Saunders
Romford, Essex
