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Preventing premature death is the aim of coroners’ Prevention of Future Deaths reports. But is this system really helping us to prevent such harms? Oxford medical student, Ali Anis, examined deaths involving cardiovascular disease and anticoagulants for his Final Honours Scheme (FHS) research, to assess the state of play, now published in BJGP Open.

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Cardiovascular disease (CVD) is the top cause of death globally. Conditions such as stroke and heart attack can be averted using anticoagulants, drugs that prevent blood from clotting for example warfarin. Higher rates of CVD have meant that prescribing of anticoagulants has risen over the past decade in England (Ho et al. 2020).

A previous study of 500 Prevention of Future Deaths reports (PFDs) found that anticoagulants were the drugs most involved in fatal medication errors (Ferner et al. 2018). So how could these deaths be prevented?

What did we do?

We conducted a case series of 3037 PFDs, published in BJGP Open (Anis et al. 2021). We used the Preventable Deaths Database and extracted information reported by coroners in deaths involving anticoagulants in people with CVD.

What did we find?

There were 113 preventable deaths involving CVD and anticoagulants over six years. Coroners raised hundreds of concerns, including issues with communication, following protocols, education and training, access to resources, and safety.

Despite these concerns having national relevance, most PFDs were sent locally to NHS Trusts, hospitals, and general practices. Those who are sent PFDs must respond within 56 days under law. However, only 29% of those recipients satisfied this act of statute. For example, one-quarter of PFDs sent to NICE had a response at the time of our analysis.

Across England and Wales, there was wide geographical variation in the issuing of PFDs (Figure 1), the information reported, and responses to PFDs.

Our complete findings are openly available in BJGP Open (Anis et al. 2021).

Limitations

The data included in our analysis is dependent on the information reported by coroners in PFDs and the reliability of the Courts and Tribunal Judiciary website, which requires an administrator to manually upload PFDs and their responses.

 

CVDanticoagmap.png

 

Figure 1: Map of the 113 PFDs involving anticoagulants and cardiovascular disease written by coroners in England and Wales between 2013 and 2019 by region created with Datawrapper by Ali Ains.

What does this mean?

Our study highlights actions are needed to improve the communication, protocols, education and training, access to resources, and safety of people with CVD who take anticoagulants.

Poor response rates to PFDs may infer that there is limited knowledge of the statutory requirements of responding to PFDs within 56 days under Regulation 29 of The Coroners (Investigations) Regulations 2013. This limits the usefulness of the PFD system as its unclear whether action was taken to prevent similar deaths, putting others at risk of harm. 

Local correspondence also limits the usefulness of PFDs and may contribute to the repeated concerns, but most importantly, unnecessary deaths. In fourteen PFDs, the lack of providing anticoagulants contributed to the death. Thus, improved awareness, guidelines, and reminders of when anticoagulation is pivotal may reduce such mistakes and facilitate a culture of learning

The geographical variation in writing PFDs may imply that coroners have differing judgments on what deaths require PFDs as previously suggested (Roberts et al. 2000), rather than that there are hotspots of premature deaths involving anticoagulants in the North West and South East of England. Nevertheless, the PFDs included in our study contained a rich source of information that could improve patient outcomes, and systematically analysing PFDs in this way is a useful task for many in the healthcare ecosystem, including for trainees, practitioners, decision makers, and patients.

Where do we go from here?

At present, the PFD system fails to prevent repeat deaths from anticoagulants in people with CVD. However, the information in PFDs is valuable and measures should be implemented to strengthen the system and improve the use of PFDs.

Clear guidance, training, and auditing of PFDs for coroners may help ensure more preventable deaths are reported across England and Wales and that the necessary information is reported in PFDs, and that PFDs are sent to the appropriate recipients. Awareness and accountability of responding to PFDs and implementing actions to prevent premature deaths could improve response rates and patient outcomes. Finally, the lessons from PFDs need to be communicated on a wider scale improve clinical practice, facilitate a learning culture, and protect patients from harm and preventable deaths. 

This research is now published in BJGP Open.

Authors

Ali Anis, Georgia C. Richards

References

Anis A, Heneghan C, Aronson JK, DeVito NJ, Richards GC. Deaths from cardiovascular disease involving anticoagulants: a systematic synthesis of coroners' case reports. BJGP Open. 2021 Oct 7:BJGPO.2021.0150. doi: 10.3399/BJGPO.2021.0150.  

Ferner RE, Easton C, Cox AR. Deaths from Medicines: A Systematic Analysis of Coroners' Reports to Prevent Future Deaths. Drug Saf. 2018 Jan;41(1):103-110. doi: 10.1007/s40264-017-0588-0.

Ho KH, van Hove M, Leng G. Trends in anticoagulant prescribing: a review of local policies in English primary care. BMC Health Serv Res. 2020 Apr 3;20(1):279. doi: 10.1186/s12913-020-5058-1.

Roberts IS, Gorodkin LM, Benbow EW. What is a natural cause of death? A survey of how coroners in England and Wales approach borderline cases. J Clin Pathol. 2000 May;53(5):367-73. doi: 10.1136/jcp.53.5.367.