Preventable Deaths Tracker

A platform to learn lessons from PFDs to prevent future deaths

Death categories

The Courts and Tribunals Judiciary classifies each Prevention of Future Deaths report (PFDs) into one or several categories, with 16 pre-defined categories. This research has been published in the Medico-Legal Journal (Zhang & Richards, 2023).

Figure 1: PFDs by category from inception (July 2013) to 22nd June 2022 (n=3997 as 4 PFDs were uncategorised). Each PFD can be labelled in multiple categories. There was a joint category between “Community Health Care” and “Emergency Services”, but since 2019, “Emergency Services” is a separate category, which we present here as two categories by assuming that deaths related to “Community Health Care and Emergency Services” are related to both categories.

There was a significant increase in the deaths related to various categories in 2021, despite the number of PFDs written in 2021 was lower than 2019. In particular, PFDs in the “alcohol, drug and medication”, “mental health”, “suicide”, “police”, “care homes”, and “product-related” deaths all increased in 2021 compared to other years.

Figure 2: The number of PFDs over time by death categories. The hospital category is scaled down by a factor of 4 for visualisation purposes.

Out of the 16 categories, 12 were introduced from inception (July 2013). These categories are presented in Figure 3.

Figure 3: The number of PFDs over time, accounting for death categories introduced from inception (July 2013)

There are four categories introduced after 2013: suicide (2015 onwards), child deaths (2015 onwards), emergency service-related deaths (2019 onwards) and Wales prevention of future deaths reports (2019 onwards). Figure 4 presents the number of PFDs in these four categories.

Figure 4: The number of PFDs over time by the four categories introduced by the Chief Coroner’s Office after inception (July 2013). “Emergency services (2019 onwards)” was a category that split off from “Community health care and emergency services-related deaths”

Mental Health

There has been a significant increase in the number of mental health-related deaths, including suicides.

Figure 5: The number of mental health-related deaths and suicides from July 2013 to 22nd June 2022. The increase in 2021 may be due to the delay in registration of these deaths during the covid-19 pandemic.

Table 1: Number of PFDs by death category, containing the subtotals by category and by year.

Yearhospitalcommunity health care emergency servicesotherroadstate custodysuicidewales prevention of future reportmental healthemergency servicesalcohol, drug and medicationpoliceaccident at work and health and safetychildcare homeproductrailway
20136429171680015062201542
201424568695934001501585028135
20152234856403115011010783625105
20162296349403346028010139352697
20172396335412420017049824291111
2018177514435223403502259213238
20192174146513755286444521273833510
202099636525135512622245105272597
20212018310527299018115216634540432811
202278133987301051123072181456
Category totals17725225253422383456841399260107602392709772