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Preventable deaths involving medicines in England and Wales, 2013-22: a systematic case series of coroners reports

By Harrison S France, Jeffrey K Aronson, Carl Heneghan, Robin E Ferner, Anthony R Cox, Georgia C Richards

Posted 02 Nov 2022
medRxiv DOI: 10.1101/2022.11.01.22281803

ObjectivesTo identify medicines-related deaths in coroners reports and to explore concerns to prevent future deaths. DesignRetrospective case series of coroners Prevention of Future Deaths reports (PFDs). SettingEngland and Wales. ParticipantsIndividuals identified in 3837 PFDs dated between 1 July 2013 and 22 February 2022, collected from the UKs Courts and Tribunals Judiciary website using web scraping, and populated into an openly available database: https://preventabledeathstracker.net/ Main outcome measuresProportion of PFDs in which coroners reported that a therapeutic medicine or drug of abuse caused or contributed to a death; characteristics of the included PFDs; coroners concerns; recipients of PFDs and the timeliness of their responses. Results704 PFDs (18%; 716 deaths) involved medicines, representing an estimated 19,740 years of life lost. Opioids (22%), antidepressants (9.7%), and hypnotics (9.2%) were the most common drugs involved. Coroners expressed 1249 concerns, primarily related to patient safety (29%) and communication (26%), including failures of monitoring (10%) and poor communication between organisations (7.5%). NHS England (6%), the Department of Health and Social Care (5%) and the Medicines and Healthcare products Regulatory Agency (2%) received the most medicines-related PFDs. However, most expected responses to PFDs (51%; 615/1245) were not reported on the UKs Courts and Tribunals Judiciary website. ConclusionsOne in five deaths deemed preventable by coroners involved medicines. Taking actions to address coroners concerns, including improving patient safety and poor communication, should increase the safety of medicines. Many concerns were raised repeatedly, but half of 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. Trial registrationhttps://doi.org/10.17605/OSF.IO/TX3CS

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