Deaths from medicines: lessons from coroners’ reports are too easily lost, review finds

Coroners’ reports often do not fulfil their statutory aim to prevent future deaths in the case of fatalities related to medicines, a report suggests.1

The researchers, led by Robin Ferner of the West Midlands Centre for Adverse Drug Reactions, said that alerting national rather than local organisations to the reports would ensure that important lessons about patient safety would be learnt.

The law in England and Wales requires coroners to write “regulation 28” reports to the appropriate bodies if an inquest reveals information that could be used to prevent future deaths. …