A systematic narrative review of coroners’ prevention of future deaths reports (PFDs): a potential metric for patient safety in hospitals

Abstract

Patient harm due to unsafe healthcare is widespread, potentially devastating, and often preventable. Hoping to eliminate avoidable harms, the World Health Organization (WHO) published the Global Patient Safety Action Plan in July 2021. The UK's National Health Service relies on several measures, including "never events", "serious incidents", patient safety events, and coroners' prevention of future death reports (PFDs) to monitor healthcare quality and safety. We conducted a systematic narrative review of PubMed and medRxiv on 19 February 2023 to explore the strengths and limitations of coroners' PFDs and whether they could be a safety metric to help meet the WHO's Global Patient Safety Action Plan. We identified 17 studies that investigated a range of PFDs, including preventable deaths involving medicines and an assessment during the COVID-19 pandemic. We found that PFDs offered important information that could support hospitals to improve patient safety and prevent deaths. However, inconsistent reporting, low response rates to PFDs, and difficulty in accessing, analysing, and monitoring PFDs limited their use and adoption as a patient safety metric for hospitals. To fulfil the potential of PFDs, a national system is required that develops guidelines, sanctions failed responses, and embeds technology to encourage the prevention of future deaths.

Preventable deaths involving sepsis in England and Wales, 2013–2022: a systematic case series of coroners’ reports

“…Studies have started to create case series of PFDs that can be analysed to identify common themes and lessons to be learned, but have yet to examine sepsis [10]. A detailed analysis of PFDs implicating sepsis could highlight important lessons for clinical practice and policy making to prevent avoidable sepsis-related deaths.…”