Deaths from cardiovascular disease involving anticoagulants: a systematic synthesis of coroners’ case reports

Anis, Ali; Heneghan, Carl; Aronson, Jeffrey K; DeVito, Nicholas J; Richards, Georgia C

doi:10.3399/bjgpo.2021.0150

Cited by 14 publications

(46 citation statements)

References 22 publications

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“…This may also require alterations to the content and recipients of PFDs to facilitate the learning of lessons elsewhere, such that they are also designed to provide general information to third parties. Our research, alongside other studies (10,12,24,34,(38)(39)(40)(41)(42)(43), highlights that PFDs contain a wealth of important information that has merit for wide dissemination. However, crucial information in PFDs is often missing, incorrect, or inconsistent.…”

Section: Interpretation and Implications For Clinicians And Policymakersmentioning

confidence: 53%

“…This difference can be attributed to the quality of our data collection methods, which allowed us to examine all available PFDs to which medicines contributed. Compared with previous studies (10)(11)(12)24,34), concerns reported by coroners were the same, except for those relating to patient safety, which has not been identified in PFDs before. However, in a study examining hospital incident reports, 18% of concerns were related to patient safety (35).…”

Section: Comparison With Previous Literaturementioning

confidence: 56%

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Preventable deaths involving medicines in England and Wales, 2013-22: a systematic case series of coroners’ reports

France

Aronson

Heneghan

et al. 2022

Preprint

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Objectives: To identify medicines-related deaths in coroners reports and to explore concerns to prevent future deaths. Design: Retrospective case series of coroners Prevention of Future Deaths reports (PFDs). Setting: England and Wales. Participants: Individuals identified in 3837 PFDs dated between 1 July 2013 and 22 February 2022, collected from the UK Courts and Tribunals Judiciary website using web scraping, and populated into an openly available database: https://preventabledeathstracker.net/ Main outcome measures: Proportion of PFDs in which coroners reported that a therapeutic medicine or drug of abuse caused or contributed to a death; characteristics of the included PFDs; coroners concerns; recipients of PFDs and the timeliness of their responses. Results: 704 PFDs (18%; 716 deaths) involved medicines, representing an estimated 19,740 years of life lost. Opioids (22%), antidepressants (9.7%), and hypnotics (9.2%) were the most common drugs involved. Coroners expressed 1249 concerns, primarily related to patient safety (29%) and communication (26%), including failures of monitoring (10%) and poor communication between organisations (7.5%). NHS England (6%), the Department of Health and Social Care (5%) and the Medicines and Healthcare products Regulatory Agency (2%) received the most medicines-related PFDs. However, most expected responses to PFDs (51%; 615/1245) were not reported on the UK Courts and Tribunals Judiciary website. Conclusions: One in five deaths deemed preventable by coroners involved medicines. Taking actions to address coroners concerns, including improving patient safety and poor communication, should increase the safety of medicines. Many concerns were raised repeatedly, but half of PFD recipients failed to respond, suggesting that lessons are not generally learned. The rich information in PFDs should be used to foster a learning environment in clinical practice that may help reduce preventable deaths. Trial registration: https://doi.org/10.17605/OSF.IO/TX3CS

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Section: Interpretation and Implications For Clinicians And Policymakersmentioning

confidence: 53%

Section: Comparison With Previous Literaturementioning

confidence: 56%

Preventable deaths involving medicines in England and Wales, 2013-22: a systematic case series of coroners’ reports

France

Aronson

Heneghan

et al. 2022

Preprint

Self Cite

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“…[6][7][8][9] Case series of PFDs have also been conducted to investigate preventable deaths from medicines and misused drugs, suicides, cardiovascular disease and cycling. [10][11][12][13] During the COVID-19 pandemic, healthcare professionals in England and Wales called for the deaths of their colleagues to be reported to coroners and for PFDs to be issued. 14 15 However, PFDs issued during the COVID-19 pandemic have not been analysed.…”

Section: Primary Carementioning

confidence: 99%

Preventable deaths from SARS-CoV-2 in England and Wales: a systematic case series of coroners’ reports during the COVID-19 pandemic

Swift

Heneghan

Aronson

et al. 2021

BMJ EBM

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ObjectivesTo examine coroners’ Prevention of Future Deaths (PFDs) reports to identify deaths involving SARS-CoV-2 that coroners deemed preventable.DesignConsecutive case series.SettingEngland and Wales.ParticipantsPatients reported in 510 PFDs dated between 01 January 2020 and 28 June 2021, collected from the UK’s Courts and Tribunals Judiciary website using web scraping to create an openly available database: https://preventabledeathstrackernet/.Main outcome measuresConcerns reported by coroners.ResultsSARS-CoV-2 was involved in 23 deaths reported by coroners in PFDs. Twelve deaths were indirectly related to the COVID-19 pandemic, defined as those that were not medically caused by SARS-CoV-2, but were associated with mitigation measures. In 11 cases, the coroner explicitly reported that COVID-19 had directly caused death. There was geographical variation in the reporting of PFDs; most (39%) were written by coroners in the North West of England. The coroners raised 56 concerns, problems in communication being the most common (30%), followed by failure to follow protocols (23%). Organisations in the National Health Service were sent the most PFDs (51%), followed by the government (26%), but responses to PFDs by these organisations were poor.ConclusionsPFDs contain a rich source of information on preventable deaths that has previously been difficult to examine systematically. Our openly available tool (https://preventabledeathstracker.net/) streamlines this process and has identified many concerns raised by coroners that should be addressed during the government’s inquiry into the handling of the COVID-19 pandemic, so that mistakes made are less likely to be repeated.Study protocol preregistrationhttps://osf.io/bfypc/.

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“…6 These reports, named Prevent Future Deaths (PFDs) are now mandated by the Coroners and Justice Act 2009 and the Coroners (Investigations) Regulations 2013. 7,8 Studies have systematically analysed PFDs to assess deaths during the COVID-19 pandemic, involving anticoagulants, medicines purchased online, medication errors and adverse drug reactions [9][10][11][12][13] . A case series of medicine-related PFDs showed that opioids were the most common drug involved in deaths.…”

Section: Introductionmentioning

confidence: 99%

Preventable deaths involving opioids in England and Wales, 2013-2022: a systematic case series of coroners’ reports

Dernie

Thomas

Bilip³

et al. 2022

Preprint

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Background: Deaths from opioids have increased in England and Wales, despite recognition of their harms. Coroners Prevention of Future Death reports (PFDs) provide important insights that may enable safer use and avert harms, yet these reports involving opioids have not been synthesised. We, therefore, aimed to identify opioid-related PFDs and explore concerns expressed by coroners to prevent future deaths. Methods: In this systematic case series, we screened 3897 coronial PFDs dated between 01 July 2013 and 23 February 2022. These were obtained by web scraping the UKs Courts and Tribunals Judiciary website to create an openly available database: https://preventabledeathstracker.net/. PFDs were included when an opioid was implicated in the death. Included PFDs were descriptively analysed, and content analysis was used to assess concerns reported by coroners and responses to such concerns. Findings: Opioids were involved in 219 deaths reported by coroners in PFDs (6% of all PFDs), equating to 4418 years of life lost (mean 32 years/person). Morphine (29%), methadone (23%), and diamorphine (16%) were the most common implicated opioids. Coroners most frequently raised concerns regarding systems and protocols (52%) or safety issues (15%). These concerns were most often addressed to NHS organisations (51%), but response rates were low overall (47%). Interpretation: Opioids could be used more safely and appropriately if coroners' concerns in PFDs were addressed by national organisations such as NHS bodies, government agencies, and policymakers, as well as individual prescribing clinicians.

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Deaths from cardiovascular disease involving anticoagulants: a systematic synthesis of coroners’ case reports

Cited by 14 publications

References 22 publications

Preventable deaths involving medicines in England and Wales, 2013-22: a systematic case series of coroners’ reports

Preventable deaths involving medicines in England and Wales, 2013-22: a systematic case series of coroners’ reports

Preventable deaths from SARS-CoV-2 in England and Wales: a systematic case series of coroners’ reports during the COVID-19 pandemic

Preventable deaths involving opioids in England and Wales, 2013-2022: a systematic case series of coroners’ reports

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