doi: medRxiv preprint NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.

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

Background Falls in older people are common, but can lead to significant harm including death. Coroners in England and Wales have a duty to report cases where action should be taken to prevent deaths, but dissemination of their findings remains poor. Objective To identify preventable fall-related deaths, classify coroners concerns, and explore organisational responses. Design Retrospective case series. Setting Coroners reports to Prevent Future Deaths (PFD) in England and Wales. Methods Web scraping was used to screen and read PFDs from the Courts and Tribunals Judiciary website from July 2013 (inception) to November 2022. Demographic information, coroners concerns and responses from organisations were extracted. Descriptive statistics and content analysis were used to synthesise data. Results 527 PFDs (12.5% of all PFDs) involved a fall that contributed to death. These deaths predominantly affected older people (median 82 years) in the community (72%), with subsequent death in hospital (70.8%). A high proportion of cases experienced fractures, major bleeding or head injury. Coroners frequently raised concerns regarding falls risks assessments, failures in communication, and documentation issues. Only 56.7% of PFDs received a response from the intended recipients. Organisations produced new protocols, improved training, and commenced audits in response to PFDs. Conclusions One in eight preventable deaths reported in England and Wales involved a fall. Addressing concerns raised by coroners should improve falls prevention and care following falls especially for older adults. Poor responses to coroners may indicate that actions are not being taken. Wider learning from PFD findings may help reduce preventable fall-related deaths.

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.

Purpose: Coroners Prevention of Future Death (PFDs) reports are an under-utilised resource to learn about preventable deaths in England and Wales. We aimed to identify sepsis-related PFDs and explore the causes and concerns in this subset of preventable sepsis deaths. Methods: 4305 reports were acquired from the Courts and Tribunals Judiciary website between July 2013 and November 2022, which were screened for sepsis. Demographic information, coroners concerns and responses to these reports were extracted and analysed, including a detailed paediatric subgroup analysis. Results: 265 reports (6% of total PFDs) involved sepsis-related deaths. The most common cause of death in these reports was 'sepsis without septic shock' (42%) and the most common site of infection was the respiratory system (18%) followed by gastrointestinal (16%) and skin (13%) infections. Specific pathogens were named in few reports (27%). Many deaths involved multimorbid patients (49%) or those with recent surgery (26%). Coroners named 773 individual concerns, the most frequent were: a failure to keep accurate records or notes (28%), failure in communication or handover (27%) or failure to recognise risk factors or comorbidities (20%). Paediatric cases frequently reported issues with sepsis screening tools (26%). Sepsis PFDs resulted in 421 individual reports being sent, of which 45% received no response. Most organisations who did respond acknowledged concerns and initiated a new change (74%). Conclusion: Sepsis-related PFDs provide valuable insights into preventable causes of sepsis and identify important sources of improvement in sepsis care. Wider dissemination of findings is vital to learn from these reports.