Background Falls in older people are common, but can lead to significant harm including death. Coroners in England and Wales have a duty to report cases where action should be taken to prevent deaths, but dissemination of their findings remains poor. Objective To identify preventable fall-related deaths, classify coroners concerns, and explore organisational responses. Design Retrospective case series. Setting Coroners reports to Prevent Future Deaths (PFD) in England and Wales. Methods Web scraping was used to screen and read PFDs from the Courts and Tribunals Judiciary website from July 2013 (inception) to November 2022. Demographic information, coroners concerns and responses from organisations were extracted. Descriptive statistics and content analysis were used to synthesise data. Results 527 PFDs (12.5% of all PFDs) involved a fall that contributed to death. These deaths predominantly affected older people (median 82 years) in the community (72%), with subsequent death in hospital (70.8%). A high proportion of cases experienced fractures, major bleeding or head injury. Coroners frequently raised concerns regarding falls risks assessments, failures in communication, and documentation issues. Only 56.7% of PFDs received a response from the intended recipients. Organisations produced new protocols, improved training, and commenced audits in response to PFDs. Conclusions One in eight preventable deaths reported in England and Wales involved a fall. Addressing concerns raised by coroners should improve falls prevention and care following falls especially for older adults. Poor responses to coroners may indicate that actions are not being taken. Wider learning from PFD findings may help reduce preventable fall-related deaths.
Purpose: Coroners Prevention of Future Death (PFDs) reports are an under-utilised resource to learn about preventable deaths in England and Wales. We aimed to identify sepsis-related PFDs and explore the causes and concerns in this subset of preventable sepsis deaths. Methods: 4305 reports were acquired from the Courts and Tribunals Judiciary website between July 2013 and November 2022, which were screened for sepsis. Demographic information, coroners concerns and responses to these reports were extracted and analysed, including a detailed paediatric subgroup analysis. Results: 265 reports (6% of total PFDs) involved sepsis-related deaths. The most common cause of death in these reports was 'sepsis without septic shock' (42%) and the most common site of infection was the respiratory system (18%) followed by gastrointestinal (16%) and skin (13%) infections. Specific pathogens were named in few reports (27%). Many deaths involved multimorbid patients (49%) or those with recent surgery (26%). Coroners named 773 individual concerns, the most frequent were: a failure to keep accurate records or notes (28%), failure in communication or handover (27%) or failure to recognise risk factors or comorbidities (20%). Paediatric cases frequently reported issues with sepsis screening tools (26%). Sepsis PFDs resulted in 421 individual reports being sent, of which 45% received no response. Most organisations who did respond acknowledged concerns and initiated a new change (74%). Conclusion: Sepsis-related PFDs provide valuable insights into preventable causes of sepsis and identify important sources of improvement in sepsis care. Wider dissemination of findings is vital to learn from these reports.
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