1
|
Jindal J, Launer D, France HS, Hey M, Song K, Portwood C, Richards G, Dernie F. Preventable deaths involving sepsis in England and Wales, 2013-2022: a systematic case series of coroners' reports. Infection 2024; 52:945-954. [PMID: 38079094 DOI: 10.1007/s15010-023-02140-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 11/14/2023] [Indexed: 06/02/2024]
Abstract
PURPOSE Coroners' Prevention of Future Death (PFDs) reports are an under-utilized resource to learn about preventable deaths in England and Wales. We aimed to identify sepsis-related PFDs and explore the causes and concerns in this subset of preventable sepsis deaths. METHODS Four thousand three hundred five reports were acquired from the Courts and Tribunals Judiciary website between July 2013 and November 2022, which were screened for sepsis. Demographic information, coroners concerns and responses to these reports were extracted and analyzed, including a detailed paediatric subgroup analysis. RESULTS Two hundred sixty-five reports (6% of total PFDs) involved sepsis-related deaths. The most common cause of death in these reports was "sepsis without septic shock" (42%) and the most common site of infection was the respiratory system (18%) followed by gastrointestinal (16%) and skin (13%) infections. Specific pathogens were named in few reports (27%). Many deaths involved multimorbid patients (49%) or those with recent surgery (26%). Coroners named 773 individual concerns, the most frequent were: a failure to keep accurate records or notes (28%), failure in communication or handover (27%) or failure to recognize risk factors or comorbidities (20%). Paediatric cases frequently reported issues with sepsis screening tools (26%). Sepsis PFDs resulted in 421 individual reports being sent, of which 45% received no response. Most organisations who did respond acknowledged concerns and initiated a new change (74%). CONCLUSION Sepsis-related PFDs provide valuable insights into preventable causes of sepsis and identify important sources of improvement in sepsis care. Wider dissemination of findings is vital to learn from these reports.
Collapse
Affiliation(s)
- Jessy Jindal
- Medical Sciences Division, University of Oxford, Oxford, OX3 9DU, UK
| | - David Launer
- Medical Sciences Division, University of Oxford, Oxford, OX3 9DU, UK
| | - Harrison S France
- Medical Sciences Division, University of Oxford, Oxford, OX3 9DU, UK
| | - Molly Hey
- Medical Sciences Division, University of Oxford, Oxford, OX3 9DU, UK
| | - Kaiyang Song
- Medical Sciences Division, University of Oxford, Oxford, OX3 9DU, UK
| | - Clara Portwood
- Medical Sciences Division, University of Oxford, Oxford, OX3 9DU, UK
| | - Georgia Richards
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Francesco Dernie
- Medical Sciences Division, University of Oxford, Oxford, OX3 9DU, UK.
- Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK.
| |
Collapse
|
2
|
Anthony G, Aronson J, Brittain R, Heneghan C, Richards G. Preventable suicides involving medicines: A systematic case series of coroners' reports in England and Wales. PUBLIC HEALTH IN PRACTICE 2024; 7:100491. [PMID: 38628605 PMCID: PMC11019265 DOI: 10.1016/j.puhip.2024.100491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/05/2024] [Accepted: 03/22/2024] [Indexed: 04/19/2024] Open
Abstract
Background In England and Wales coroners have a duty to write a report, called a Prevention of Future Deaths report or PFD, when they believe that actions should be taken to prevent future deaths. Coroners send PFDs to individuals and organisations who are required to respond within 56 days. Despite the increase in mental health concerns and growing use of medicines, deaths reported by coroners that have involved medicine-related suicides had not yet been explored. Therefore, this study aimed to systematically assess coroners' PFD reports involving suicides in which a medicine caused or contributed to the death to identify lessons for suicide prevention. Methods Using the Preventable Deaths Tracker database (https://preventabledeathstracker.net/), 3037 coroners' PFD reports in England and Wales were screened for eligibility between July 2013 and December 2019. Reports were included if they involved suicide or intentional self-harm and prescribed or over-the-counter medication; illicit drugs were excluded. Following data extraction, descriptive statistics, document and content analysis were performed to assess coroners' concerns and the recipients of reports. Results There were 734 suicide-related coroner reports, with 100 (14%) reporting a medicine. Opioids (40%) were the most common class involved, followed by antidepressants (30%). There was wide geographical variation in the writing of reports; coroners in Manchester wrote the most (18%). Coroners expressed 237 concerns; the most common were procedural inadequacies (14%, n = 32), inadequate documentation and communication (10%, n = 22), and inappropriate prescription access (9%, n = 21). 203 recipients received the PFDs, with most sent to NHS trusts (31%), clinical commissioning groups (10%), and general practices (10%), of which only 58% responded to the coroner. Conclusions One in four coroner reports in England and Wales involved suicides, with one in seven suicide-related deaths involving a medicine. Concerns raised by coroners highlighted gaps in care that require action from the Government, health services, and prescribers to aid suicide prevention. Coroner reports should be routinely used and monitored to inform public health policy, disseminated nationally, and responses to coroners should be transparently enforced so that actions are taken to prevent future suicides.
Collapse
Affiliation(s)
- G. Anthony
- Oxford University Medical School, John Radcliffe Hospital, Headington, University of Oxford, Oxford, OX3 9DU, UK
| | - J.K. Aronson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - R. Brittain
- St Pancras Coroner's Court, London, N1C 4PP, UK
| | - C. Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - G.C. Richards
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| |
Collapse
|
3
|
Hodgson S, O'Mahony K, Nicholson J, Williams P. Thematic analysis of 'Prevention of Future Deaths' reports related to emergency departments in England and Wales 2013-2022. Emerg Med J 2024; 41:184-186. [PMID: 38050124 DOI: 10.1136/emermed-2023-213445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 12/06/2023]
Affiliation(s)
- Sarah Hodgson
- Emergency Department, Raigmore Hospital, Inverness, UK
| | | | - James Nicholson
- Highland Medical Education Centre, Raigmore Hospital, Inverness, UK
- Resuscitation Research Group, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
| | | |
Collapse
|
4
|
Coroners' reports, medicines and preventable deaths. Drug Ther Bull 2023; 61:165. [PMID: 37748844 DOI: 10.1136/dtb.2023.000048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Overview of: France hs, aronson JK, heneghan c, et al. preventable deaths involving medicines: a systematic case series of coroners' reports 2013- 22. Drug Saf 2023;46:335-42.
Collapse
|
5
|
Song K, Portwood C, Jindal J, Launer D, France H, Hey M, Richards G, Dernie F. Preventable deaths involving falls in England and Wales, 2013-22: a systematic case series of coroners' reports. Age Ageing 2023; 52:afad191. [PMID: 37847796 DOI: 10.1093/ageing/afad191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Falls in older people are common, leading to significant harm including death. Coroners have a duty to report cases where action should be taken to prevent future deaths, but dissemination of their findings remains poor. OBJECTIVE To identify preventable fall-related deaths, classify coroner concerns and explore organisational responses. DESIGN A retrospective systematic case series of coroners' Prevention of Future Deaths (PFD) reports, from July 2013 (inception) to November 2022. SETTING England and Wales. METHODS Reproducible data collection methods were used to web-scrape and read PFD reports. Demographic information, coroner concerns and responses from organisations were extracted and descriptive statistics used to synthesise data. RESULTS Five hundred and twenty-seven PFDs (12.5% of PFDs) involved a fall that contributed to death. These deaths predominantly affected older people (median 82 years) in the community (72%), with subsequent death in hospital (70.8%). A high proportion of cases experienced fractures (51.6%), major bleeding (35.9%) or head injury (38.7%). Coroners frequently raised concerns regarding falls risks assessments (20.9%), failures in communication (20.3%) and documentation issues (17.5%). Only 56.7% of PFDs received a response from organisations to whom they were addressed. Organisations tended to produce new protocols (58.5%), improve training (44.6%) and commence audits (34.3%) in response to PFDs. CONCLUSIONS One in eight preventable deaths in England and Wales involved a fall. Addressing concerns raised by coroners should improve falls prevention and care following falls especially for older adults, but the poor response rate may indicate that lessons are not being learned. Wider dissemination of PFD findings may help reduce preventable fall-related deaths in the future.
Collapse
Affiliation(s)
- Kaiyang Song
- Medical Sciences Division, University of Oxford, Oxford OX3 9DU, UK
| | - Clara Portwood
- Medical Sciences Division, University of Oxford, Oxford OX3 9DU, UK
| | - Jessy Jindal
- Medical Sciences Division, University of Oxford, Oxford OX3 9DU, UK
| | - David Launer
- Medical Sciences Division, University of Oxford, Oxford OX3 9DU, UK
| | - Harrison France
- Medical Sciences Division, University of Oxford, Oxford OX3 9DU, UK
| | - Molly Hey
- Medical Sciences Division, University of Oxford, Oxford OX3 9DU, UK
| | - Georgia Richards
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK
| | | |
Collapse
|
6
|
Ferner RE, Brittain R, Cox AR, Heneghan C, Richards GC, Aronson JK. Recognition of Coroners' Concerns to Prevent Future Deaths from Medicines: A Systematic Review. Pharmaceut Med 2023; 37:357-363. [PMID: 37421561 DOI: 10.1007/s40290-023-00486-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Coroners, who hold inquests to determine the causes of unnatural deaths in England and Wales, having recognised factors that could cause other deaths, are legally obliged to signal concerns by sending 'Reports to Prevent Future Deaths' (PFDs) to interested persons. We aimed to establish whether Coroners' concerns about medications are widely recognised. METHODS We searched MEDLINE, Embase and Web of Science up to 30 November, 2022 for publications linking PFDs and medications using a combination of search terms "coroner*", "inquest*", "medicine*", "medication*" and "prevent*". We also searched the BMJ, a UK journal that carries news items; and the databases Nexis Advance and News On the Web for reports in national newspapers between 2013 and 2022, using the search terms ("regulation 28" OR "prevent future deaths" OR "prevention of future deaths") AND "coroner". We recorded the number of publications, as well as their citations in Google Scholar at 23 May, 2023. RESULTS Only 11 published papers on medicines referenced UK PFDs, nine of which were from our group. The BMJ carried 23 articles mentioning PFDs, five related to medicines. Of 139 PFDs (out of over 4000) mentioned in national newspapers, only nine related to medicines. CONCLUSIONS The PFDs related to medicines are not widely referred to in medical journals or UK national newspapers. By contrast, the Australian and New Zealand National Coronial Information System has contributed cases to 206 publications cited in PubMed, of which 139 are related to medicines. Our search suggests that information from English and Welsh Coroners' PFDs is under-recognised, even though it should inform public health. The results of inquiries by Coroners and medical examiners worldwide into potentially preventable deaths involving medicines should be used to strengthen the safety of medicines.
Collapse
Affiliation(s)
- Robin E Ferner
- Institute of Clinical Sciences, University of Birmingham, Birmingham, B15 2TT, UK.
- West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham, B18 7QH, UK.
| | | | - Anthony R Cox
- Institute of Clinical Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Carl Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Georgia C Richards
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Jeffrey K Aronson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| |
Collapse
|