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

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Abstract

Introduction

Medicines cause over 1700 preventable deaths annually in England. Coroners’ Prevention of Future Death reports (PFDs) are produced in response to preventable deaths to facilitate change. The information in PFDs may help reduce medicine-related preventable deaths.

Objectives

We aimed to identify medicine-related deaths in coroners’ reports and to explore concerns to prevent future deaths.

Methods

We carried out a retrospective case series of PFDs across England and Wales, dated between 1 July, 2013 and 23 February, 2022, collected from the UK’s Courts and Tribunals Judiciary website using web scraping, generating an openly available database: https://preventabledeathstracker.net/. We used descriptive techniques and content analysis to assess the main outcome criteria: the proportion of PFDs in which coroners reported that a therapeutic medicine or drug of abuse had caused or contributed to a death; the characteristics of included PFDs; coroners’ concerns; the recipients of PFDs; and the timeliness of their responses.

Results

There were 704 PFDs (18%; 716 deaths) that involved medicines, representing an estimated 19,740 years of life lost (average of 50 years lost per death). Opioids (22%), antidepressants (9.7%), and hypnotics (9.2%) were the most common drugs involved. Coroners expressed 1249 concerns, primarily around the major themes of patient safety (29%) and communication (26%), including minor themes of failures of monitoring (10%) and poor communication between organizations (7.5%). Most expected responses to PFDs (51%; 630/1245) were not reported on the UK’s Courts and Tribunals Judiciary website.

Conclusions

One in five coroner-reported preventable deaths involved medicines. Addressing coroners’ concerns, including problems with patient safety and communication, should reduce harms from medicines. Despite concerns being raised repeatedly, half of the 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.

Clinical Trial Registration

https://doi.org/10.17605/OSF.IO/TX3CS.

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Author information

Authors and Affiliations

  1. Oxford Medical School, Medical Sciences Divisional Office, University of Oxford, Oxford, OX3 9DU, UK

    Harrison S. France

  2. Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK

    Jeffrey K. Aronson, Carl Heneghan & Georgia C. Richards

  3. West Midlands Centre for Adverse Drug Reactions, Birmingham, UK

    Robin E. Ferner & Anthony R. Cox

  4. College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK

    Robin E. Ferner & Anthony R. Cox

Authors
  1. Harrison S. France
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  4. Robin E. Ferner
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  5. Anthony R. Cox
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  6. Georgia C. Richards
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Corresponding author

Correspondence to Harrison S. France.

Ethics declarations

Funding

No funding was obtained for this study. An Engagement and Dissemination grant (2020) and Seedcorn funding (2021) was obtained from the National Institute of Health Research (NIHR) School for Primary Care Research to develop the Preventable Deaths Tracker website: https://preventabledeathstracker.net/.

Conflicts of Interest/Competing Interests

All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/disclosure-of-interest/ and declare no support from any organization for the submitted work. HSF has received scholarships (2020–22) from Brasenose College, University of Oxford and Fidelity National Information Services for undergraduate study, from the British Pharmacological Society (2022) for meritorious performance in a research competition and received payments (2022) from Brasenose College, University of Oxford for undergraduate teaching. JKA has published papers in bioscience journals and edited textbooks on adverse drug reactions; he has often acted as an expert witness in civil actions relating to suspected adverse drug reactions and in coroners’ courts. CH holds grant funding from the NIHR, the NIHR School of Primary Care Research. CH has received expenses and fees for his media work, for teaching EBM and is also paid for his GP work in the National Health Service out of hours (contract Oxford Health National Health Service Foundation Trust). CH is the Director of the Centre for Evidence-based Medicine. REF has undertaken research and published on adverse drug reactions and medication errors. REF has acted as an expert witness in coronial and other legal cases related to these. ARC holds grant funding from Cancer Alliance. ARC has received fees for media work, a scientific advisory committee at IQVIA, and external examinations at UK Universities. ARC is the Head of the School of Pharmacy at the University of Birmingham and is an honorary pharmacovigilance pharmacist at the West Midlands Centre for Adverse Drug Reaction Reporting. GCR is the director of a limited company that is independently contracted to work as an epidemiologist and teach at the University of Oxford. GCR received scholarships (2017–20) from the National Health Service NIHR School for Primary Care Research, the Naji Foundation, and the Rotary Foundation to study for a DPhil at the University of Oxford. The study guarantor affirms that the article is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned and registered have been explained.

Ethics Approval

This study exclusively uses publicly available information, for which ethics committee approval is not required.

Consent to Participate

Patient consent was not sought for this study, which exclusively used publicly available information regarding deceased individuals.

Consent for Publication

Not applicable.

Availability of Data and Material

All study materials, data, and statistical code are openly available via online repositories. The study protocol was preregistered on the OSF (https://doi.org/10.17605/OSF.IO/TX3CS); the code to generate the database and the Preventable Deaths Tracker is openly available via GitHub (https://github.com/georgiarichards/georgiarichards.github.io); individual Prevention of Future Deaths reports are available on the Courts and Tribunals Judiciary website (https://www.judiciary.uk/prevention-of-future-death-reports/); and all other study materials are openly available via the OSF project page (https://doi.org/10.17605/OSF.IO/WQ7G5).

Code Availability

The code to generate the database and the Preventable Deaths Tracker is openly available via GitHub (https://github.com/georgiarichards/georgiarichards.github.io).

Author contributions

HSF updated the study protocol, carried out screening of PFDs, extracted remaining data, conducted all analyses, produced all figures and tables, and wrote the first draft of the manuscript. GCR conceptualized, designed, and initiated the study; provided supervisory support, and edited the first draft of the manuscript. REF and ARC contributed to the study conceptualization. CH and JKA provided supervisory support and oversight. REF and JKA provided clinical pharmacological advice and interpretation. All study authors read, contributed to, and approved the final manuscript. HSF is the guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

Additional information

Preprint uploaded to MedRxiv. Available at: https://doi.org/10.1101/2022.11.01.22281803.

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France, H.S., Aronson, J.K., Heneghan, C. et al. Preventable Deaths Involving Medicines: A Systematic Case Series of Coroners’ Reports 2013–22. Drug Saf 46, 335–342 (2023). https://doi.org/10.1007/s40264-023-01274-8

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