Preventing future deaths: what have we learnt from reports into preventable fatalities?

Last year, coroners opened 36 900 inquests into deaths in England and Wales. They included some of the most traumatic and sensitive deaths in these countries: deaths in state detention, deaths of children, suicides, and drug related fatalities.

Of these deaths, 569 were deemed to have been avoidable by the coroners examining them, compelling them to set out how such deaths could be prevented in the future. However, there’s little evidence that these recommendations are being listened to.

Coroners in the UK have been able to issue prevention of future deaths reports (PFDRs) since 2013, as part of reforms introduced by the Coroners and Justice Act 2009. The reports enable coroners to raise any matters of concern if this may prevent future deaths. At the time of publication, 5249 such reports have been published. This September, one such report warned that a common practice used by anaesthetists could lead to deaths, after concluding that a woman had died because she received too large a dose of a local anaesthetic during an operation.1

However, there’s a growing body of opinion and evidence that the report system isn’t working as it should. “The really important question, that no one is asking, is what is the effectiveness of PFDRs in saving lives?” says Georgia Richards, teaching fellow in evidence based medicine at Oxford University and founder of the Preventable Deaths Tracker2 (see box). She developed the tracker during her PhD to research deaths attributed to opioids.