Preventable deaths in cases of violence against women and girls in England and Wales
Creators: name: Pluddemann, Annette
name: Heneghan, Katie
name: Richards, Georgia C.
Publisher: name: Open Science Framework
Year: 2023
Subjects: subject: Social and Behavioral Sciences
subject: Medicine and Health Sciences
subject: Law
subject: FOS: Law
subject: preventable deaths
subject: PFDs
subject: violence
subject: deaths
subject: homicide
subject: femicide
subject: domestic violence
subject: coroner reports
subject: women &amp; girls

description: A systematic case series of coroners' reports in England and Wales 2013-22 1.0 Background Globally, deaths involving females are less likely than males to be registered and have a valid cause of death (1). The most recent statistics of prevalence across a lifetime (year ending March 2020), from the UK Government, show over 27% of women had experienced a form of domestic abuse since the age of 16 (2). In the year ending March 2022, 7% of women aged 16 and over were victims of domestic abuse and 3% of women aged 16 and over were victims of sexual assault, in England and Wales (3). In the year ending March 2020, 81 women were killed in a domestic homicide - equivalent to 46% of adult female homicide victims (4). There are tragic high-profile cases of female victims of homicides reported, such as Sarah Everard, Julia James, Bibaa Henry and Nicole Smallman, but the occurrences of violence are likely to be under reported (5). Violence against women and girls can encompass a range of abuse types, which affect women and girls more than men and boys, including domestic homicide, domestic abuse, sexual assault, abuse experienced as a child, female genital mutilation (FGM), forced marriage, and harassment (6). Qualitative studies into public awareness and attitudes towards domestic violence support the need for the introduction of sustained interventions, such as the suggestion for National Institute for Clinical Excellence (NICE) to consider ‘recommending the routine use of a rapid screening tool for domestic violence’ (7). In February 2014, NICE published guidelines for multi-agency services, aiming to help identify, prevent and reduce domestic violence and abuse (8). The Government’s Domestic Abuse Act is regularly updated, including consultation in 2018 from NHS England, to tackle domestic abuse ‘at every stage from prevention through to rehabilitation’ (9). Currently, in England and Wales, domestic homicide reviews (DHRs) are also conducted to identify lessons to be learned in domestic abuse-related deaths. However, their emergency as a ‘policy initiative has been little considered’, with criticism DHRs contain differences in participant status and concerns with system functioning, access, and quality to these reviews, which cannot replace coroners’ reports (10). Since 1984, in England and Wales, coroners have had a duty to report and communicate details of deaths when the coroner believes that action should be taken to prevent future deaths (11). These reports, named Prevention of Future Deaths reports (PFDs), are mandated under Paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009, and under Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 (12). When a person or organization receives a PFD from a coroner, they have 56 days in which they must respond by statute. However, there is no mechanism in place to enforce, audit or analyse PFDs, their responses, or the inactions and potential actions taken. Several case series have been conducted on coroners’ PFDs, involving medicines, cardiovascular diseases, and deaths during the covid-19 pandemic (https://preventabledeathstracker.net/research/) (13). However, no study has investigated PFDs specifically in women and girls, nor has an investigation into preventable deaths involving violence been conducted. Furthermore, PFDs are often biased towards a predominance of both male cases reported to coroners and the proportion of cases proceeding to inquest (14), and when female deaths do process to inquest they are less likely to result in a verdict of unnatural death than male deaths (15). 2.0 Aims and objectives We aim to systematically analyse coroners’ concerns in PFDs in which instances of violence against women and girls were attributed to the death. Our objectives are to discover: 1. the number of PFDs involving violence against women and girls that caused or contributed to the death, and the nature of the death. 2. the number and the types of concerns raised in PFDs involving violence against women and girls. 3. the number and type of recipients who received these PFDs and their rates of responses. 4. assess the actions taken or proposed in responses, or any inactions to prevent future deaths in cases of violence against women and girls.