Norfolk's Health Overview Select Committee has agreed to write to Ministers highlighting what members described as a significant gap in national oversight of Prevention of Future Deaths notices — the formal warnings issued by coroners when an inquest identifies systemic failures that could cause future deaths.

The vote, proposed by Cllr Lucy Galvin and seconded by Cllr Stuart Dark, was passed unanimously at the 19 March 2026 meeting. The draft letter will be circulated to committee members for approval before being sent.

The issue arose during a scrutiny session on Norfolk and Suffolk NHS Foundation Trust (NSFT). Officers confirmed that no Prevention of Future Deaths notices had been issued to the Trust since November 2024, but committee members discussed how the notices are applied inconsistently by coroners in different regions.

Cllr Emma Corlett, a local member who spoke at the meeting, had questioned the lack of notices given recurring themes emerging from inquests into the deaths of mental health patients.

Committee members agreed that regional variation in how the system works demonstrates the need for a national framework to ensure consistent oversight.

The committee also agreed separately to request detailed information on every area of NSFT's services rated 'Requires Improvement' by the Care Quality Commission, including data on patient deaths, support offered to families after traumatic incidents, and how the Trust embeds learning from serious events.