Deaths involving adolescents reported by coroners in England and Wales: a systematic case series
Creators: name: Richards, Georgia C.
name: Thomas, Elizabeth
name: Barton-Sargeant, Caitlin
Publisher: name: OSF Registries
Year: 2024
Subjects: subject: Medicine and Health Sciences
subject: Social and Behavioral Sciences
subject: Law
subject: FOS: Law
subject: PFDs
subject: adolescents
subject: coroners reports
subject: deaths
subject: preventable deaths
subject: suicide

description: Adolescence is defined by the World Health Organisation (WHO) as individuals aged 10-19 years [1]. During these ages, adolescents will experience significant physical, cognitive, emotional, and social development. In England and Wales, 1169 adolescent deaths were registered in 2022 which constitutes the second-greatest mortality rate amongst children and young people, following only infant deaths [2]. The most common causes of death in adolescents were accidents (20%) of which the majority were transport-related, followed by cancer (15%) and intentional self-harm (14%) [2]. However, the mortality rates of adolescents in England and Wales have plateaued in recent years and have not matched the reductions observed in comparative high-income European countries [3,4].

Deaths of those aged under 18 in England are reviewed by a local Child Death Overview Panel (CDOP) and are entered into the National Child Mortality Database (NCMD) [5]. The NCMD is then routinely analysed and used to produce reports, research, and recommendations. For example, the NCMD was used to assess suicide rates before the COVID-19 pandemic, which found the highest rates to be amongst those aged 15-17 with males exhibiting greater suicide rates than females [6]. The database has also been used to examine all-cause mortality rates in 10-17 year olds, which showed no significant differences before or after the pandemic and no evidence that suicide rates increased [7,8]. In addition, for those aged 10-17, the NCMD has shown a positive correlation between increased risk of death and deprivation measures [9]. However, the NCMD does not include data from Wales, excludes adolescents aged 18-19 years and only contains data from 1 April 2019.

In England and Wales, coroners have a duty to report and communicate a death if they believe that action should be taken to prevent future deaths. Such reports, known as Prevention of Future Deaths reports (PFDs) have been made openly available on the Courts and Tribunal Judiciary website since July 2013. Upon receipt of a PFD report, an individual and/or organisation has 56 days to respond to the coroner. Prior to the Preventable Deaths Tracker [10], there was no database of PFDs. The Preventable Deaths Tracker database has enabled the systematic collection of reports and has conducted several case series, including deaths involving medicine-related suicides, opioids, sepsis, and deaths during the COVID-19 pandemic [11-14]. However, an analysis of deaths involving adolescents has not yet been carried out. 

Aims and Objectives
We aim to systematically analyse coroners’ concerns in PFDs that report on deaths in adolescents aged 10 to 19 years. 

Our objectives are to:
1. Determine the number of PFDs which report on deaths of adolescents.
2. Assess the causes of deaths in adolescent deaths reported by coroners. 
3. Explore the types of concerns raised by coroners in PFDs involving adolescents.
4. Determine the number and types of recipients to whom the PFDs were addressed, and whether a response was received within the 56-day requirement. 
5. Examine the degree of action taken by individuals or organisations in response to PFDs to prevent future deaths in adolescents.