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

Abstract

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.

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

“…This is the first study to focus on sepsis-related PFDs, or PFDs related to any infectious cause of death. Previous studies of PFDs investigating deaths relating to medicines, opioids, and falls have also identified a poor response rate and lack of standardisation in PFD content [13,22,23]. These concerns were also identified in a House of Commons Justice Select Committee [24].…”