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Coroner’s refusal to issue a Prevention of Future Deaths Report following death in prison custody inquest was lawful

09 January 2023

R (Diarra Dillon) v HM Assistant Coroner for Rutland and North Leicestershire [2022] EWHC 3186 (KB)

An inquest touching upon the death of Eshea Nile Dillon, which occurred in prison, led to the family applying for a judicial review of the coroner’s decision to not issue a PFD report. 

Mr Dillon experienced breathing difficulties in his cell and called for assistance by pressing his cell bell. A prison officer provided advice but did not enter the cell as he was unaware that he was able to without another officer present. 

The jury returned a narrative conclusion and did not conclude that anything done (or not done) by prison officers contributed to Mr Dillon’s death. The coroner heard evidence in relation to staff understanding of emergency procedures, first aid training and reaching prisoners in emergencies and decided not to make a PFD report in light of the MOJ’s implementation of actions (spot checks to be done to ensure staff understanding on those points) would address those risks and the threshold for issuing a PFD report therefore was not met.

Following a judicial review, the Court held that the Coroner had not been irrational in refusing to make a PFD report. She had been entitled to consider the Ministry of Justice’s implementation of actions required to address risks relating to prison officers’ understanding of emergency procedures. This included the introduction of spot checks and a new Compact. The Prison Service’s ‘commitment to take action’ was also a factor that the Coroner was entitled to take into account in deciding that the threshold and formality of a PFD report had not been met. 

The court endorsed the Chief Coroner’s Guidance at paragraph 4, which states that PFD reports should (among other things) be meaningful and, wherever possible, designed to have a practical effect. 

This case demonstrates the practical effect of the discretionary nature of PFD’s and the importance of interested persons answering questions on risk reduction, management and mitigation.



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