Preventable Deaths Tracker

A platform with the only database of coroner reports in the UK.

by on

New publication in the Medico-Legal Journal

On Monday, 23 January 2022, the Medico-Legal Journal published our latest analysis of Prevention of Future Deaths reports (PFDs) (Zhang & Richards, 2023).

This research was led by Oxford Physics student, Qingyang Zhang, in the Summer (June-August) of 2022 during an Internship. Qingyang writes below about her experience and findings.

In the summer of 2022, I had the amazing opportunity to intern as a research assistant for Dr Georgia Richards on the Preventable Deaths Tracker. I collected data on Prevention of Future Deaths reports (PFDs) from the UK’s Courts and Tribunals Judiciary website and analysed trends of these coroner reports.

What are PFDs?

A Prevention of Future Deaths report (PFD) is written when coroners believe that a death could have been prevented. For example, following the Westminster attack in March 2017, coroners wrote a report highlighting actions that the police, ambulance, and fire brigade could have done to prevent such tragic events from happening again, and sent this report to the leaders responsible for those services. Then the recipients of the report must, by law, respond to the coroner describing the changes taken or being made to prevent future deaths.

What did I learn?

A LOT!

  1. The Courts and Tribunals Judiciary website is poorly designed and contains countless typos and inconsistencies, making it difficult to efficiently and effectively conduct research. This challenged me to improve my coding skills to extract the necessary information from the website.
  2. I learned that there were 16 different categories that PFDs are assigned to on the Judiciary website, with the most common (44%) being hospital-related deaths. PFDs relating to mental health, including suicides, increased significantly. 
  3. There was geographical variation in the writing of PFDs with most written by coroners in London and Manchester.
  4. Responses to coroners’ PFDs were poor, with one in three PFDs (36%; N = 1412) not having an available response.
  5. Fewer PFDs were written in Wales than in England, and there was a dip in PFD written in 2020, suggesting that factors like the Covid-19 pandemic can impact the number of preventable deaths being reported. 

Lastly, I am so grateful for Dr Georgia Richards’ mentorship and for helping me publish my first academic paper. I massively improved my programming skills and this internship gave me more clarity for planning my next career steps.

Our complete analysis and publication is openly here: https://doi.org/10.1177/00258172221141284