Preventable Deaths Tracker

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

Research using coroners’ PFD reports

We conduct bespoke analyses and studies of coroner reports to identify trends and lessons for improving public safety and reducing avoidable harm. We have published over 25 studies, articles, and reports to date, including:

New studies

  1. Jindal et al. 2024. Preventable Maternal Deaths in England and Wales 2013–2023 – a systematic case series of coroners’ reports. medRxiv. https://doi.org/10.1101/2024.07.09.24310137

Systematic reviews

  1. Bremner et al. 2023. A systematic narrative review of coroners’ prevention of future deaths reports (PFDs): a tool for patient safety in hospitals. Journal of Patient Safety and Risk Management. https://doi.org/10.1177/25160435231198685
  2. Ferner et al. 2023. Recognition of coroners’ concerns to prevent future deaths from medicines: a systematic review. Pharmaceutical Medicine. https://doi.org/10.1007/s40290-023-00486-8

Medicines

  1. Dernie et al. 2023. Preventable deaths involving opioids in England and Wales, 2013-2022: a systematic case series of coroners’ reports. Journal of Public Health. https://doi.org/10.1093/pubmed/fdad147
  2. France et al. 2023. Preventable Deaths Involving Medicines: A Systematic Case Series of Coroners’ Reports 2013–22. Drug Safety. https://doi.org/10.1007/s40264-023-01274-8
  3. Aronson et al. 2021. Deaths attributed to the use of medications purchased online. BMJ Evidence Based Medicine. 27:60-64. http://dx.doi.org/10.1136/bmjebm-2021-111759
  4. Cox & Ferner. 2020. Tramadol: repeated prescriptions and repeated warnings. BMJ Evidence Based Medicine; 26:e17. http://dx.doi.org/10.1136/bmjebm-2020-111661
  5. Thomas & Richards. 2020. Diclofenac in adolescents: diagnosing and treating gastrointestinal adverse drug reactions can prevent future deaths. BMJ Evidence Based Medicine. http://dx.doi.org/10.1136/bmjebm-2020-111640
  6. Ferner et al. 2019. Preventing Future Deaths from Medicines: Responses to Coroners’ Concerns in England and Wales. Drug Safety. 42:445-451. https://doi.org/10.1007/s40264-018-0738-z
  7. Ferner et al. 2018. Deaths from Medicines: A Systematic Analysis of Coroners’ Reports to Prevent Future Deaths. Drug Safety. 41:103–110. https://doi.org/10.1007/s40264-017-0588-0
  8. Ferner & Whittington .1994. Coroner’s cases of death due to errors in prescribing or giving medicines or to adverse drug reactions: Birmingham 1986-1991. Journal of the Royal Society of Medicine. https://doi.org/10.1177/014107689408700311

Products

  1. Bilip & Richards. 2020. Emollients and smoking: a fire hazard that could be prevented to reduce future deaths. BMJ Evidence Based Medicine. 26:131-134. http://dx.doi.org/10.1136/bmjebm-2020-111648
  2. Richards. 2020. Alcohol-based hand sanitisers: a warning to mitigate future poisonings and deaths. BMJ Evidence Based Medicine. 26:65-68. http://dx.doi.org/10.1136/bmjebm-2020-111568

Infectious diseases

  1. Jindal et al. 2023. Preventable deaths involving sepsis in England and Wales, 2013-2022: a systematic case series of coroners reports. Infection. https://doi.org/10.1007/s15010-023-02140-6
  2. France. 2022. Pandemics, Pharmacology, and Preventable Deaths. Pharmacology Matters. https://www.bps.ac.uk/publishing/pharmacology-matters/august-2022/pandemics,-pharmacology,-and-preventable-deaths
  3. Swift et al. 2021. Preventable deaths from SARS-CoV-2 in England and Wales: a systematic case series of coroners’ reports during the COVID-19 pandemic. BMJ Evidence Based Medicine. 27:296-304. http://dx.doi.org/10.1136/bmjebm-2021-111834

Mental health

  1. Anthony et al. 2024. Preventable suicides involving medicines: A systematic case series of coroners’ reports in England and Wales. Public Health in Practice. https://doi.org/10.1016/j.puhip.2024.100491

Cardiovascular diseases

  1. Anis et al. 2021. Deaths from cardiovascular diseases involving anticoagulants: a systematic synthesis of coroners’ case reports. BJGP Open. https://doi.org/10.3399/BJGPO.2021.0150

Accidents & external causes

  1. Song et al. 2023. Preventable deaths involving falls in England and Wales, 2013-2022: a systematic case series of coroners reports. Age & Ageing. https://doi.org/10.1093/ageing/afad191
  2. Ferner et al. 2023. Rapid response Re: Rising fatalities, injuries, and NHS costs: dog bites as a public health problem. The BMJ. https://www.bmj.com/content/381/bmj.p879/rr-1

Transport

  1. Odgers et al. 2021. Preventable deaths involving cyclists in England and Wales: Solutions to improve their safety. Report: https://www.gchu.org.uk/2021/09/gchu-report-preventable-deaths-involving-cyclists-in-england-and-wales/

Healthy Cities

  1. Loo & Richards. 2021. Preventable deaths in Oxford and Oxfordshire. Report: https://www.gchu.org.uk/2021/12/gchu-report-preventable-deaths-in-oxford-and-oxfordshire/
  2. De La Haye & Richards. 2021. Preventable deaths in the city of Cambridge and Cambridgeshire, UK. Report: https://www.gchu.org.uk/2021/12/gchu-report-preventable-deaths-in-cambridge-and-cambridgeshire/

Methods papers

  1. Zhang & Richards. 2023. Lessons from web scraping coroners’ Prevention of Future Deaths reports. Medico-Legal Journal. https://doi.org/10.1177/00258172221141284
  2. DeVito et al. 2020. How we learnt to stop worrying and love web scraping. Nature. https://doi.org/10.1038/d41586-020-02558-0

Editorials

  1. Richards et al. 2020. Coroners’ concerns to prevent harms: a series of coroners’ case reports to serve patient safety and educate the public, clinicians and policy-makers. BMJ Evidence Based Medicine. 26:37-38. http://dx.doi.org/10.1136/bmjebm-2020-111567

Commentaries & letters

  1. Aronson. 2023. When I use a word . . . Preventable deaths and public awareness. The BMJ. 382:p1811. https://doi.org/10.1136/bmj.p1811
  2. Aronson. 2023. When I use a word … Coroners’ duties: enquiry and prevention. The BMJ. 382: p1759. https://doi.org/10.1136/bmj.p1759
  3. Aronson. 2022. When I use a word . . . Too little healthcare—coroners’ concerns. The BMJ. 379:o2873. https://doi.org/10.1136/bmj.o2873
  4. Aronson. 2018. Rapid response to Deaths from medicines. The BMJ. 363:k4322. https://www.bmj.com/content/363/bmj.k4322/rapid-responses

Ongoing research

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