Preventable deaths involving medicines in England and Wales, 2013-22: a systematic case series of coroners reports
Abstract
Objectives: To identify medicines-related deaths in coroners reports and to explore concerns to prevent future deaths. Design: Retrospective case series of coroners Prevention of Future Deaths reports (PFDs). Setting: England and Wales. Participants: Individuals identified in 3837 PFDs dated between 1 July 2013 and 22 February 2022, collected from the UK Courts and Tribunals Judiciary website using web scraping, and populated into an openly available database: https://preventabledeathstracker.net/ Main outcome measures: Proportion 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. Results: 704 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 UK Courts and Tribunals Judiciary website. Conclusions: One in five deaths deemed…
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Evidence Hub reads this as a case series, done in people. Its evidence level is 5 of 5 (Very low · case / narrative / animal / in vitro / in silico). Case reports, narrative reviews, and animal, cell or computer-model studies give the weakest evidence for human health.
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