Richards et al. Learning from Preventable Deaths

Learning from Preventable Deaths

8 February 2023


We’re an interdisciplinary group of six academics, clinicians, and a coroner from the University of Oxford, the University of Birmingham, and London. Dr Georgia Richards is a Health Scientist and Epidemiologist that has been leading and conducting work on Prevention of Future Deaths reports (PFDs) and the Preventable Deaths Tracker ( for more than five years, including completing a Doctor of Philosophy (DPhil/PhD) at the University of Oxford on preventable deaths involving opioids. Dr Jeffrey Aronson and Professor Robin Ferner are Clinical Pharmacologists that have acted as expert witnesses in coronial courts and other legal cases for decades. Dr Richard Brittain is a medically trained Assistant Coroner that has professional experience writing PFDs in practice and has been contributing to our research. Professor Anthony Cox is a Clinical Pharmacist and Head of the School of Pharmacy at the University of Birmingham with extensive research experience on drug safety and PFDs. Professor Carl Heneghan is an NHS urgent care general practitioner, Clinical Epidemiologist and Director of the Centre for Evidence-Based Medicine at the University of Oxford with decades of experience synthesising evidence on excess and preventable deaths. We make this submission to the Prevention inquiry after reading and analysing more than 4,000 PFDs and working with coroners and bereaved families, which has highlighted that more must be done in health and social care to learn lessons from preventable deaths. 



Death is the most serious and objective marker of harm. However, not all deaths are inevitable. Treatment and prevention are two mechanisms by which deaths can be averted. Fortunately, there are systems in place from which lessons from deaths can be learnt, including coroners’ Prevention of Future Deaths reports (PFDs). Coroners write PFDs when it is important to share information about a death that requires actions to be taken to prevent further deaths, which are mandated under The Coroners and Justice Act 2009 and The Coroners (Investigation) Regulations 2013. However, lessons are not widely shared and implemented, and as a consequence, health and social care services fail to learn from PFDs.


In 2020, 23 per cent of all deaths in Great Britain were considered avoidable, statistically significantly more than in all years since 20101. In particular, alcohol and drug-related deaths have increased statistically significantly since 20011. In English hospitals alone, it is estimated that over 10,000 adult deaths per year are preventable2.


As part of this submission, we summarise 12 published studies that we have conducted on the concerns raised by coroners in PFDs. These are summarized in Table 13–14.


Preventable deaths highlighted by coroners in PFDs exhibit a wide variety of issues that require addressing. For example, we identified two PFDs that reported deaths in NHS hospitals following intentional and unintentional consumption of alcohol-based hand sanitisers10. If lessons had been widely shared across the NHS following the publication of the first PFD in 2014 then actions could have been taken in all NHS hospitals and the second death in 2015 from the unintentional consumption of alcohol-based hand sanitisers by a 76-year-old man with vascular dementia would have been prevented.


By analysing PFDs, repeat hazards can be identified and prevented. We found several cases of fatal fires from people using emollient and paraffin-based creams, which are readily available in prescription and over-the-counter products and commonly used in homes and healthcare facilities. Several PFDs have highlighted the fire risk and flammability of these creams as well as the lack of public and professional knowledge of these risks. In a particular case9, the coroner sent the PFD to six organizations, including the Department for Health and Social Care (DHSC), the National Institute for Health and Care Excellence (NICE) and Public Health England, but only three responded despite The Coroners (Investigation) Regulations 2013 requiring a response within 56 days. Since this PFD, further preventable deaths involving emollients have occurred 15 as there is no process in place to confirm the implementation of actions discussed in the addressees’ responses. Thus, lessons are not being learned and actions are still required.


PFDs provide an opportunity to develop and implement mitigation strategies and an opportunity to educate healthcare professionals and the public about harm reduction. We identified 18 preventable deaths reported in 17 PFDs between November 2013 and December 2019 that were associated with the online purchasing of medicines, two of which involved the dark web4. Despite the complexity of regulating online sales of medicines, the synthesis of these PFDs offers healthcare workers, policymakers, and the public important lessons that could prevent future deaths from purchasing medicines online.


When PFDs are addressed appropriately, their actions can help prevent deaths. For example, a PFD was sent to NICE when the deceased fell while taking an anticoagulant without having appropriate neuroimaging performed, resulting in the updating of NICE guidance on head injury13. However, three-quarters of PFDs sent to NICE had no responses available.


Overall, our research illustrates that PFDs have the potential to significantly reduce years of life lost. For example, we found that one in five PFDs (716 deaths) involved medicines, equating to nearly 20,000 years of life lost7. However, a systematic approach is required to improve the system due to the current failings so that lessons can be learnt from PFDs and deaths prevented.


In 2020 we developed an online tool, the Preventable Deaths Tracker (, to improve the accessibility, searchability, and monitoring of PFDs and their responses. Since its establishment, the Preventable Deaths Tracker receives thousands of users a month, with 8,900 individual users in January 2023 alone. Bereaved families access it as well as advocacy groups (e.g. INQUEST), the Chief Coroner’s Office, the Ministry of Justice, NHS pharmacists, academics, investigative journalists, the media and the public.


As part of the Prevention inquiry, we recommend

  1. A select committee is established to obtain an overview of preventable deaths in the UK, the current strategies to reduce them and the shortcomings in current processes that can be addressed.
  2. An assessment of the current publication and dissemination process of PFDs that are sent to health and social care services, highlighting coroners' concerns and the actions taken or proposed in responses.
  3. An examination of lessons highlighted by coroners and their level of implementation across jurisdictions that aim to prevent future deaths.
  4. The commissioning of an independent national oversight mechanism that can collate, analyse, and monitor the lessons and responses to PFDs.
  5. An overview of the methods by which excess and preventable deaths are identified, analysed and highlighted within existing systems.
  6. The development of a systematic approach to improve the system so that lessons can be learnt from PFDs and deaths can be prevented.


Correspondence to Dr Georgia Richards (, who can supply further information and oral evidence.



Table 1: Summary of published research on coroners’ Prevention of Future Deaths reports


Types of PFDs


Anis et al. 2022 3

113 CVD-related PFDs involving anticoagulants, published between Jul 2013 and Dec 2019.

        Warfarin, enoxaparin, and rivaroxaban were most involved in CVD-related PFDs.

        Poor systems, communication, and failures in medical records were the most common concerns reported by coroners.

        PFDs were often sent to NHS trusts, hospitals, and general practices, but 60% had not received responses.

        PFDs offer lessons for prescribers and policymakers on the safety and appropriate use of therapies.

        It is unclear whether changes are being made to incorporate lessons from PFDs; thus, acting on PFDs at a national level would help to prevent deaths.

Aronson et al. 2022 4

17 PFDs, published between Nov 2018 and Dec 2019, describing online purchase of medicines or non-medicinal chemicals, which contributed to deaths.

        Two PFDs reported that products, which caused death, were obtained from the dark web.

        Prescription-only medications were the most involved drugs purchased online.

        Mental health and drug dependence/abuse were common contributory factors.

        Concerns included ease of obtaining medicines, the regulation of supply and importation of medicines, including the regulation of the dark web, and the lack of a limit on the amount and frequency of orders.

        90% of PFD recipients did not respond to the coroner within the legal time limit (56 days).

        PFDs offered healthcare workers, policymakers, and the public lessons regarding purchasing medicines online.

Bilip & Richards 2021 9

One PFD relating to paraffin-based emollient creams


        There were frequent fires involving paraffin-based creams, mostly in elderly residents;

        There is a wide availability of paraffin-based creams and a lack of awareness of their fire risk; the risk of potential build up on clothing and the lethal outcomes of these fires.

        The PFD was sent to several national organizations, including the DHSC, who responded by outlining actions previously taken in response to deaths involving paraffin-based emollients.

        Of the six organizations to which the PFD was addressed, only three had responded by January 2021.

        Further emollient deaths have occurred after this PFD; thus, lessons were not learned, and actions are still needed.

Cox & Ferner 2021 5

Two PFDs associated with tramadol

        PFDs highlighted the dangers of repeat prescribing of tramadol, the importance of communicating its risks, and the need for evidence-based solutions to prevent future harms.

        Actions on individual cases reported in PFDs could be used to prevent deaths more broadly if communication and adoption were more widespread.

Dernie et al. 2022 6

219 PFDs involving opioids

        For every opioid-related PFD, a median of 33 years of life were lost.

        Morphine, methadone, and heroin were most often involved.

        Coroners’ concerns were frequently related to systems and protocols and maintaining accurate medical records and plans for patients taking opioids.

        Concerns were most often addressed to NHS organizations.

        Responses to PFDs were poor (47% overall), and their lessons were only disseminated locally.

        Issuing PFDs depends on the working practices of individual coroners; the process is neither audited nor assessed.

Ferner et al. 2019 13

Responses to 69 of 99 PFDs relating to medicines, published between Apr 2015 and Sep 2016 from 106 organizations

        Common actions taken by organizations were staff education or training and changes to processes or policy, although some organizations reported existing policies were sufficient.

        The median time taken for organizations to respond to PFDs was 53 days.

        Coroners often brought to light systemic failures of general importance that prompted actions that otherwise would not have been completed.

        Important concerns are often shared only locally, preventing widespread learning from nationally relevant lessons.

        Few responses to PFDs are published, and little information is provided as to why.

Ferner et al. 2017 14

99 PFDs in which medicines or the medication process was identified, published between April 2015 and September 2016

        Anticoagulants, antidepressants, and drugs of abuse were the most mentioned medicines.

        Adverse reactions to prescribed medications, omission of necessary treatment, failure to monitor treatment, and poor systems were the most highlighted concerns.

        Concerns were related to issues in education or training, lack of clear guidelines or protocols, and failure to implement existing guidelines.

        Pharmacovigilance could benefit if health organisations, professional and regulatory bodies, and market authorisation holders were more aware of PFDs.

France et al. 2022 7

704 PFDs involving medicines, published between Jul 2013 and Feb 2022

        1 in 5 PFDs involved medicines (716 deaths)

        19,740 years of life were lost

        Opioids, antidepressants, and hypnotics were the most common medicines involved

        Patient safety and communication were the most common concerns raised by coroners

        NHS England, DHSC, and MHRA were the organizations who most often received medicines-related PFDs

        51% of expected responses were not available

        Addressing coroners’ concerns could feasibly improve the safety of medicines.

        PFDs contain important information and have the potential to contribute to a learning environment in clinical practice that could prevent future deaths.

        The current PFD system does not take steps to enforce or audit responses to PFDs, despite the legal requirement.

        Concerns should be shared more broadly to ensure that national lessons are learnt.

Richards 2021 10

Two PFDs describing deaths from ingestion of alcohol-based hand sanitisers

        There were eight recommendations to prevent intentional and accidental ingestion of alcohol-based hand sanitisers in healthcare and community settings.

        PFDs provide an ‘opportunity to develop and implement mitigation strategies’ and ‘an opportunity to educate healthcare professionals and the public in harm reduction’.

        No process is in place to confirm the implementation of actions discussed in the addressees’ responses.

        Coroners’ concerns were not widely communicated in the NHS despite being addressed to NHS England.

Swift et al. 2022 11

23 PFDs relating to SARS-CoV-2, published between Jan 2020 and Jun 2021

        communication problems and the failure to follow protocols were the most common coroners' concerns

        NHS organizations, and the Government were the most common recipients of PFDs; however, response rates were poor.

        There was significant geographical variation in the reporting of PFDs.

        Coroners’ concerns should be considered during the UK Government’s inquiry into the handling of the pandemic so that repeated mistakes can be avoided.

        There is no formal system by which PFDs are currently audited or analysed, so coroners’ concerns may go unreported and unrecognised.

Thomas & Richards 2021 8

One PFD attributed to a non-steroidal anti-inflammatory drug (NSAID), diclofenac


        Adverse drug reactions from NSAIDs should be considered in children and adolescents, especially those with complex needs.

        There were missed opportunities for further testing and observations that resulted in systematic failures in the documentation and transmission of information.

        No response to the PFD from the NHS trust had been published (>4 years overdue).

Zhang & Richards 2022 12

A review of all available PFDs (N=4001), published between Jul 2013 and Jun 2022

        The most common category assigned to PFDs were ‘hospital (clinical procedures and medical management)” related deaths. However, 73% of deaths on the Courts and Tribunals Judiciary website were not categorized.

        There was significant geographical variation in PFD writing: 20 coroners were responsible for 30% of all PFDs.

        One in three (36%) PFDs were without responses

        The Courts and Tribunals website had significant problems with poor categorization, missing information, and formatting issues; many PFDs contained misspellings and formatting inconsistencies.

        Poor management and standardization within the Courts and Tribunals website limit the analysis of PFDs.

        Technology can simplify the process of auditing PFDs and ensure that changes are made to prevent future deaths.

        PFDs hold a rich source of information that decision-makers should use to improve public health and safety.

PFD: prevention of future death report; CVD: cardiovascular disease; NHS: National Health Service; MHRA: Medicine and Healthcare products Regulatory Agency; DHSC: Department of Health and Social Care.


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2.              Hogan, H. et al. Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Qual. Saf. 21, 737–745 (2012).

3.              Anis, A., Heneghan, C., Aronson, J. K., DeVito, N. J. & Richards, G. C. Deaths from cardiovascular disease involving anticoagulants: a systematic synthesis of coroners’ case reports. BJGP Open 6, (2022).

4.              Aronson, J. K., Ferner, R. E. & Richards, G. C. Deaths attributed to the use of medications purchased online. BMJ Evid Based Med 27, 60–64 (2022).

5.              Cox, A. R. & Ferner, R. Tramadol: repeated prescriptions and repeated warnings. BMJ Evidence-Based Medicine (2021) doi:10.1136/bmjebm-2020-111661.

6.              Dernie, F. et al. Preventable deaths involving opioids in England and Wales, 2013-2022: a systematic case series of coroners’ reports. medRxiv (2022) doi:10.1101/2022.11.16.22282411.

7.              France, H. S. et al. Preventable deaths involving medicines in England and Wales, 2013-22: a systematic case series of coroners reports. medRxiv (2022) doi:10.1101/2022.11.01.22281803.

8.              Thomas, E. T. & Richards, G. C. Diclofenac in adolescents: diagnosing and treating gastrointestinal adverse drug reactions can prevent future deaths. BMJ Evid Based Med (2021) doi:10.1136/bmjebm-2020-111640.

9.              Bilip, M. K. & Richards, G. C. Emollients and smoking: a fire hazard that could be prevented to reduce future deaths. BMJ Evid Based Med (2021) doi:10.1136/bmjebm-2020-111648.

10.              Richards, G. C. Alcohol-based hand sanitisers: a warning to mitigate future poisonings and deaths. BMJ Evid Based Med (2020) doi:10.1136/bmjebm-2020-111568.

11.              Swift, B., Heneghan, C., Aronson, J., Howard, D. & Richards, G. C. Preventable deaths from SARS-CoV-2 in England and Wales: a systematic case series of coroners’ reports during the COVID-19 pandemic. BMJ Evid Based Med (2021) doi:10.1136/bmjebm-2021-111834.

12.              Zhang, Q. & Richards, G. C. Lessons from web scraping coroners’ Prevention of Future Deaths reports. Med. Leg. J. 00258172221141284 (2023).

13.              Ferner, R. E., Ahmad, T., Babatunde, Z. & Cox, A. R. Preventing Future Deaths from Medicines: Responses to Coroners’ Concerns in England and Wales. Drug Safety vol. 42 445–451 Preprint at (2018).

14.              Ferner, R. E., Easton, C. & Cox, A. R. Deaths from Medicines: A Systematic Analysis of Coroners’ Reports to Prevent Future Deaths. Drug Saf. 41, 103–110 (2017).

15.              MHRA. Skin creams dried on fabric can lead to fire deaths. MHRA (2020).