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

Swift, Bethan; Heneghan, Carl; Aronson, Jeffrey K; Howard, David; Richards, Georgia C

doi:10.1101/2021.07.15.21260589

Cited by 9 publications

(8 citation statements)

References 25 publications

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“…Our research, alongside other studies (10,12,24,34,38–43), 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: Discussionsupporting

confidence: 55%

“…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: 55%

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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: Discussionsupporting

confidence: 55%

Section: Comparison With Previous Literaturementioning

confidence: 55%

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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“…30 Fortunately, the value of PFDs as a tool for improving clinical practice is being recognised, and efforts are underway to widely disseminate their lessons to healthcare professionals, policymakers, and the public. 31 – 36 …”

Section: Discussionmentioning

confidence: 99%

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

et al. 2021

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BackgroundThe global burden of cardiovascular disease (CVD) is forecast to increase, and anticoagulants will remain important medicines for its management. Coroners' Prevention of Future Death reports (PFDs) provide valuable insights that may enable safer and more effective use of these agents.AimTo identify CVD-related PFDs involving anticoagulants.Design and SettingRetrospective observational study of coronial case reports in England and Wales between 2013 and 2019.MethodWe screened 3037 PFDs for eligibility and included PFDs where CVD and an anticoagulant caused or contributed to the death. We descriptively analysed included cases and used content analysis to assess concerns raised by coroners and who responded to them.ResultsWe identified 113 cardiovascular disease-related PFDs involving anticoagulants. Warfarin (36%), enoxaparin (11%), and rivaroxaban (11%) were the most common anticoagulants reported. Concerns most frequently raised by coroners included poor systems (31%), poor communication (25%), and failures to keep accurate medical records (25%). These concerns were most often directed to NHS trusts (29%), hospitals (10%), and general practices (8%). Nearly two-thirds (60%) of PFDs had not received responses from such organisations, which are mandatory under regulation 28 of the Coroners' (Investigations). We created a publicly available tool, https://preventabledeathstracker.net/, which displays coroners’ reports in England and Wales to streamline access and identify important lessons to prevent future deaths.ConclusionNational organisations, healthcare professionals, and prescribers should take actions to address the concerns of coroners’ in PFDs to improve the safe use of anticoagulants in patients with cardiovascular disease.

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“…We extracted a series of cases from the Courts and Tribunals Judiciary website and analysed them according to a study protocol that was preregistered on an open repository 16…”

Section: Methodsmentioning

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

Cited by 9 publications

References 25 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

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

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

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