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

Abstract

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.

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

“…Eight studies (47%) explored PFDs describing medicines and drugs that had caused or contributed to deaths 15,16,19,[24][25][26]29,30 , two studies assessed PFDs involving chemical products, including paraffin-based emollient creams and alcohol-based hand sanitisers 21,28 , one study examined PFDs involving diagnostic errors 27 , four publications explored healthcare-related PFDs 17,18,20,22 , and two studies analysed PFDs using a selection of categories from the Courts and Tribunals Judiciary website 13,23 (Table 1). Across these studies, preventable deaths often occurred in hospitals.…”

“…Two PFDs associated with tramadol PFDs highlighted the dangers of repeat prescribing of tramadol, the importance of communicating its risks, and the need for evidence-based solutions to prevent future harms. Dernie et al 2022 16…”

“…Studies investigating PFDs have highlighted that they contain rich information and provide essential lessons. Thirteen studies 13,15,16,[18][19][20][21][22][23][24][25][26]29 illustrated the potential of PFDs to drive improvements in hospitals and prevent deaths if coroners' concerns were addressed (Supplement Table S4). For example, lives lost in hospital tragedies, such as the Gosport scandal 31 , could have been prevented if concerns documented in PFDs had been widely disseminated to ensure that actions were taken nationally to safeguard patients.…”

“…Two studies 18,22 showed considerable differences in the quality, detail, length, and structure of reports. Missing information and errors were frequently identified, including failure to disclose the date of birth or age at death, the names or classes of medicines implicated 15,16,20,22,29 , misspelled names, and incorrect dates 13,22 , all of which impair the usefulness of PFDs. In a survey of 32 coroners in 2010-2011, in which they were asked to state and describe their purpose, only six mentioned the importance of preventing deaths as part of their purposes, and only four specifically mentioned PFDs as a tool for doing so 32 .…”

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

“…Several studies have investigated coroners' concerns in PFDs [23][24][25][26][27][28][29], yet none have focussed on fall-related deaths. In a study investigating anticoagulant-using cardiovascular disease-related PFDs [24], concerns related to inadequate use of protocols were raised in 36.0% of cases, a concern similarly prevalent in our own fall-related cases.…”