Preventable deaths involving medicines in England and Wales, 2013-22: a systematic case series of coroners’ reports
Authors: France Harrison S , Aronson Jeffrey K , Heneghan Carl , Ferner Robin E , Cox Anthony R , Richards Georgia C 
Published: November 2022

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 3897 PFDs dated between 1 July 2013 and 23 February 2022, collected from the UK’s 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 (average of 50 years lost per death). 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’s 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

Summary box

What is already known on this topic?

Medicines are essential to the provision of healthcare, but if used inappropriately, have the potential to cause significant harms, including death. When an unnatural death occurs, these deaths are often reported to the coroner, which can result in a report to highlight concerns to prevent future deaths. Samples of coroners’ reports have been analysed to identify concerns relating to preventable deaths involving medicines, which found that anticoagulants contributed the most. However, an investigation of all available reports has not been conducted to determine the overall impact of medicines.

What this study adds?

One in five preventable deaths in England and Wales involved a medicine or drug of misuse, costing nearly 20,000 years of life lost. Opioids, antidepressants, and hypnotics were the most common medicines involved in preventable deaths. Coroners repeatedly raised similar concerns, primarily relating to patient safety and communication. However, it is unclear whether these reports are being used in clinical practice to guide actions to prevent similar deaths.