Preventable Deaths Tracker

A platform to explore concerns raised by coroners' to prevent future deaths

Since 1984, coroner's in England and Wales have had a duty to report and communicate a death when the coroner believes that action should be taken to prevent similar deaths, under The Coroners Rule 1984. 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 the insufficient monitoring of the statutory requirement of responding to PFDs, and taking action. We have created this website - the Preventable Deaths Tracker - to collate and display the data of PFDs in a visual, filterable, and searchable format that others can use. We also launch the Coroners' Concerns to Prevent Harms series in BMJ Evidence Based Medicine to disseminate important lessons that serve patient safety, and prevents similar deaths.

Research & dissemination

We have a number of active research projects that are systematically analysing the database, including an assessment of suicides and deaths from opioids and medical events. We are writing monthly case reports in BMJ Evidence Based Medicine to highlight and communicate key lessons to prevent serious fatal and non-fatal harms.

The first article in the series, available here, was published on December 01, 2020 to raise awareness of the harms from ingesting alcohol-based hand sanisiter during a time where our exposure to hand sanitisers is high.

The database

The data in the below table were obtained from the Courts and Tribunals Judiciary Website. To collate the data, we ran a web scrape which is available in our Github repository. We have written about the web scrape in Nature, "How we learnt to stop worrying and love web scraping".

Data as of 18 September 2020

This is work in progress. If you think you can help improve the tracker or have questions/suggestions, please get in touch georgia.richards@kellogg.ox.ac.uk