Preventable deaths involving medicines in England and Wales, 2013-22: a systematic case series of coroners’ reports

Abstract

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

When I use a word . . . . Preventing future deaths—problems and solutions

“…For example, in our own recent survey of 3785 reports from coroners, the coroners received responses to only 49% of the medicines-related reports, 12 despite the fact that by law responses must be received within 56 days.…”

When I use a word . . . . Too little healthcare—coroners’ concerns

“…Since 2013, 19% of 3785 PFDs have reported deaths associated with medicines, with opioids (22%), antidepressants (9.7%), and hypnotics (9.2%) being most commonly involved 1. Concerns that coroners expressed often related to patient safety (29%) and communication (26%), including failures of monitoring (10%) and poor communication between organisations (7.5%).…”

“…Individuals or organisations that receive a PFD are statutorily required to respond to the coroner within 56 days of receiving the report, outlining actions proposed or already taken to tackle the concerns that the coroner has expressed. Since 2013, 19% of 3785 PFDs have reported deaths associated with medicines, with opioids (22%), antidepressants (9.7%), and hypnotics (9.2%) being most commonly involved 1. Concerns that coroners expressed about these deaths often related to patient safety (29%) and communication (26%), including failures of monitoring (10%) and poor communication between organisations (7.5%).…”

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

“…Several studies have investigated coroners' concerns in PFDs [9][10][11][12][13][14] , yet none has focused exclusively on opioid-related deaths, although opioids have previously been implicated as the most common medicine type causing preventable deaths 14 . These studies have similarly found poor response rates from recipients receiving PFDs 9,25 and wide geographical variation in the writing of reports 9,26 , concerns that were also highlighted in a 2021 report by the House of Commons Justice Select Committee.…”

“…A case series of medicine-related PFDs showed that opioids were the most common drug involved in deaths. 14 However, these concerns have not been synthesised. A systematic assessment of opioid-related PFDs and their associated responses might therefore provide valuable information to inform public health strategies to reduce opioid deaths.…”