Safety concerns reported by coroners following fentanyl patch fatalities in England, Wales and Northern Ireland between 1997 and 2024

Abstract Aim To identify safety concerns reported by coroners following fentanyl patch‐related deaths in England, Wales and Northern Ireland, and determine differences in coronial reporting. Methods A systematic case series linking the National Programme on Substance Use Mortality (NPSUM) and the Preventable Deaths Tracker (PDT) ( https://preventabledeathstracker.net/ ) to identify fentanyl patch‐related deaths. Keyword searches for ‘patches’ were conducted, and reports were screened for eligibility in duplicate. Data were extracted and descriptively analysed, and deaths were categorized by safety events. Results There were 99 fentanyl patch‐related deaths between 1997 and 2024, with 89 reported to NPSUM and 12 Prevention of Future Deaths reports (PFDs) from the PDT, with only two duplicates across both databases. Seventy‐seven safety events were reported by coroners, with adherence and usage (34%), administration (32%) and prescribing (6%) being the most common. Compared with deaths reported to NPSUM, PFDs were more common for females (58% vs . 33%), older adults (median age: 53 vs . 45 years), occurred more in hospital (42% vs . 9%), were of accidental manner (83% vs . 22%), and were prescribed patches (100% vs . 54%). A live dashboard of PFDs was developed to continue surveillance https://preventabledeathstracker.net/case-study/fentanyl-patches/ ). Conclusions Safety events, including poor adherence, usage and administration errors of fentanyl patches, were repeatedly identified by coroners, which mostly occurred in males aged 35–49 years. Information from coroners should be systematically monitored to inform the safety of prescribing and use of fentanyl patches, including identifying gaps in care, education and policies. Protocol registration https://doi.org/10.17605/OSF.IO/GMHNW