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Prevention of future deaths (PFD) report finds that the rejection of his appeal that he was not fit for work was a ‘trigger’ in Stephen Carré’s death.

What: Coroner Tom Osborne sends a PFD report (known at the time as a Rule 43 letter) regarding the death of Stephen Carré to the Department for Work and Pensions. In the letter, Osborne says the “trigger” that led Stephen to his decision to take his own life had been “the rejection of his appeal that he was not fit for work”, and he adds: “I feel the decision not to seek medical advice from the claimant’s own GP or psychiatrist if they are suffering a mental illness should be reviewed.”

Why significant: Although there was no publicity at the time, the existence of the PFD warning would emerge later, and would show that ministers had been warned that changes to the WCA system needed to be made to prevent further deaths, but that those changes had never been made. The reference to the failure to seek further medical evidence would prove hugely important in future years.  At this stage WCA outcomes were in their early stages and up to this point 64% had been found fit for work – suggesting a strict testing regime.


‘DWP and Atos killed my son’, Pring, 2015
ESA: outcomes of Work Capability Assessments April 2013 - GOV.UK ( (using the April 2013 XL data table, see table 2 'new claims by month of assessment').