This blog is written by Oxford Medical Student and Lead Author, Harrison France, following the publication of our research in the journal Drug Safety: Preventable Deaths Involving Medicines: A Systematic Case Series of Coroners’ Reports 2013–22
I had the pleasure of working with Dr Georgia Richards on the Preventable Deaths Tracker programme for my undergraduate research thesis between the summer of 2021 and the winter of 2023.
The programme of research assesses coroners’ Prevention of Future Deaths reports (PFDs)— reports that are written by coroners in England and Wales following an inquest when they believe that actions should be taken to stop similar deaths in the future. PFDs are sent to individuals or organisations with the ability to make changes, who must respond to the coroner within 56 days.
We carried out an investigation of 3,897 PFDs that were published between July 2013 and February 2022 on the Courts and Tribunals Judiciary website. I manually screened the nearly 4,000 cases to identify PFDs in which a therapeutic medicine or illicit drug caused or contributed to death.
We found 704 (18% of all PFDs) that involved medicines, representing 19,740 years of life lost. Opioids were the most commonly mentioned medicine (22%), but substantial contributions also came from antidepressants (10%), and hypnotics (9%). Coroners were most commonly concerned about issues with failures in patient monitoring (10%) and communication between different organisations (8%). All of our findings are published in Drug Safety (France et al. 2023).
Our findings highlight concerns regarding medicine-related deaths that could have been prevented. However, only half of these PFDs had responses available, limiting the ability of lessons to be learnt from medicine-related PFDs. A system that ensures accountability and responsibility for monitoring and analysing PFDs is required to prevent future deaths.
As a part of this project, I had the pleasure of presenting our findings at three conferences, including being a keynote presenter at EBMLive in Oxford (18-20 July 2022). I produced a poster for IUPHAR’s World Smart Medicine Day student research poster competition on medicine-related PFDs before and during the covid-19 pandemic, which ranked first in the UK and third globally!
I am extremely grateful to Dr Georgia Richards and the rest of the Preventable Deaths Tracker team for providing such great support throughout the project and guiding me in my first venture into the world of academia and public health.