How can avoidable deaths be prevented?

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The phrase “State related deaths” might mean little to the average person, but it's an umbrella term referring to a death in custody or a mental health setting. It also applies to situations when people have taken their own lives while in the armed forces or even to disasters like Grenfell or Hillsborough. What all these have in common is that they are followed by inquests or public inquiries, where investigators or coroners try to work out what caused the deaths. Public inquiries are set up to draw conclusions and release their findings, and coroners are required to write a "Prevention of Future Deaths" report when there are lessons to be learned. Hundreds of these PFD reports are released…