Oxford research team, led by Dr Georgia Richards, launched the Coroners’ Concerns to Prevent Harms series in BMJ Evidence Based Medicine to disseminate important lessons that serve patient safety and prevent similar deaths, educating the public, clinicians and policy-makers, and leading to the creation of The Preventable Deaths Tracker.

Under The Coroners Rule 1984, coroners in England and Wales have a duty to report and communicate a death when the coroner believes that action should be taken to prevent similar deaths. In 2013, these reports, named Prevent Future Deaths or PFDs, became mandated under Paragraph 7 of Schedule 5 of The Coroners and Justice Act 2009, and regulations 28 and 29 of The Coroners (Investigations) Regulations 2013. Under these regulations, parties that receive a PFD report are required to respond to the coroner within 56 days of receiving the report, to outline actions taken or proposed that address the coroner’s concerns.

WHY IS THIS WORK IMPORTANT?

Understanding the causes of deaths and how they can be prevented is critical for improving healthcare outcomes. At a population level, over-reporting or under-reporting of deaths can have a profound impact on policy decisions, which in turn affect global economies and the day-to-day lives of citizens. At the individual level, understanding how and why deaths occur may prevent similar deaths or serious harms from occurring in the future.

One in 20 people are exposed to preventable harms in medical settings globally, and 12% of preventable harms result in disability or death. In the UK, 22.5% of all deaths were considered avoidable in 2019. Yet only 526 PFDs were published that year. Wider communication of PFD coroner reports, and the actions taken or proposed, could have helped prevent thousands of deaths.

PREVENTABLE DEATHS TRACKER 

While many recognise the important lessons outlined by coroners in PFDs, the lack of communication of the lessons and the insufficient auditing of the statutory requirement of responding to PFDs and taking action limits their use. As a result, our researchers created the Preventable Deaths Tracker, which is trying to change this by making it accessible to all. The Tracker also shares systematic analyses of this information, to warn against repeat hazards and highlight important lessons to improve public safety, reduce avoidable harms, and prevent premature deaths. Its Preventable Deaths Database collates and displays the data from PFDs in a visual, filterable, and searchable format that others can use to affect patient outcomes. 

This website was built by Georgia Richards in collaboration with One Ltd and members of the Centre for Evidence-Based Medicine (CEBM) and DataLab at the University of Oxford.

FURTHER RESEARCH

Further research specific to alcohol-based hand sanitisers was also produced by Georgia Richards, revealing that if ingested, they can have toxic effects and may even be lethal. Preventable deaths from ingesting hand sanitisers have been identified and an article was published in the BMJ, 1 Dec 2020, describing two Prevent Future Death (PFD) case reports, recommending eight actions to mitigate intentional and accidental ingestion of alcohol-based hand sanitisers in healthcare and community settings.

FUNDING

The Preventable Deaths Tracker website was funded by the NHS National Institute for Health (NIHR) School for Primary Care Engagement and Dissemination grant 2020-2021. The views expressed are those of the research team and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.