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  • Team: Georgia Richards, Jeffrey K Aronson, Carl Heneghan
  • Theme: Communicating evidence
  • Completed projects

Oxford researcher, led by Primary Care DPhil student, 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, leading to the creation of The Preventable Deaths Tracker.

Background

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.

Method

The team discuss Coroners’ concerns to prevent harms series, referencing case reports and disseminating important lessons that serve patient safety and prevent similar deaths, to serve patient safety and educate the public, clinicians and policy-makers. This work was published in the BMJ, 1 Dec 2020.

Conclusion

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.

Many recognise the important lessons outlined by coroners in PFDs, but concerns have been raised regarding the lack of wider communication of these lessons, and insufficient monitoring of the statutory requirement of responding to PFDs and taking action. As a result, our researchers created this website – the Preventable Deaths Tracker – and the Preventable Deaths Database to collate and display the data from PFDs in a visual, filterable, and searchable format that others can use.

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 Primary Care DPhil student, 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.