Preventable Deaths Involving Medicines: A Systematic Case Series of Coroners’ Reports 2013–22

France, Harrison S; Aronson, Jeffrey K; Heneghan, Carl; Ferner, Robin E; Cox, Anthony R.; Richards, Georgia C

doi:10.1007/s40264-023-01274-8

Cited by 15 publications

(34 citation statements)

References 22 publications

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“…After screening and removing duplicates, 17 studies 13,15–30 that examined PFDs in England and Wales were included (Figure 3).…”

Section: Resultsmentioning

confidence: 99%

“…In this narrative review, we identified 17 studies 13,[15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] that analysed PFDs in England and Wales. PFDs documenting deaths related to medicines and drugs were explored most (47%; n = 8), followed by deaths involving healthcare (24%; n = 4) and chemical products (12%; n = 2).…”

Section: Discussionmentioning

confidence: 99%

“…Coroners' practices vary and are not monitored or audited. Three studies 13,23,24 showed significant variability in the rate at which individual coroners produce PFDs, and six studies 13,15,20,22,23,29 have reported geographical variation (Supplement Table S4). 13 When an unnatural or unclear death occurs, it may be reported to a coroner.…”

Section: Limitations Of Pfdsmentioning

confidence: 99%

“…The impact of PFDs is yet to be fully elucidated, as studies of their effectiveness in improving clinical practice and policy have not been conducted. Several authors 15,16,18,22,24,26,29 have reported that coroners raised repeated concerns, suggesting that PFDs did not result in the implementation of remedial actions. For example, a case report of two deaths from The search strategy used for PubMed and medRxiv databases is available in Supplement Tables S2 and S3.…”

Section: Limitations Of Pfdsmentioning

confidence: 99%

“…To access and analyse information in PFDs requires many hours (and years) of manual labour. Four studies 13,15,16,24 showed that PFDs were poorly or incorrectly categorised on the Courts and Tribunals website, with 73% of PFDs (n=2939) not assigned to any category, 13 creating ambiguities and impairing the ability to compare PFDs with national data (e.g. from the Office of National Statistics) and international data, which use internationally recognised classification systems to report deaths (e.g.…”

Section: Limitations Of Pfdsmentioning

confidence: 99%

See 4 more Smart Citations

A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): A tool for patient safety in hospitals

Bremner,

Heneghan,

Aronson

et al. 2023

Journal of Patient Safety and Risk Management

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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 Deaths 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 tool 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 tool 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.

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“…After screening and removing duplicates, 17 studies 13,15–30 that examined PFDs in England and Wales were included (Figure 3).…”

Section: Resultsmentioning

confidence: 99%