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Recognition of Coroners’ Concerns to Prevent Future Deaths from Medicines: A Systematic Review

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Abstract

Background

Coroners, who hold inquests to determine the causes of unnatural deaths in England and Wales, having recognised factors that could cause other deaths, are legally obliged to signal concerns by sending ‘Reports to Prevent Future Deaths’ (PFDs) to interested persons. We aimed to establish whether Coroners’ concerns about medications are widely recognised.

Methods

We searched MEDLINE, Embase and Web of Science up to 30 November, 2022 for publications linking PFDs and medications using a combination of search terms “coroner*”, “inquest*”, “medicine*”, “medication*” and “prevent*”. We also searched the BMJ, a UK journal that carries news items; and the databases Nexis Advance and News On the Web for reports in national newspapers between 2013 and 2022, using the search terms (“regulation 28” OR “prevent future deaths” OR “prevention of future deaths”) AND “coroner”. We recorded the number of publications, as well as their citations in Google Scholar at 23 May, 2023.

Results

Only 11 published papers on medicines referenced UK PFDs, nine of which were from our group. The BMJ carried 23 articles mentioning PFDs, five related to medicines. Of 139 PFDs (out of over 4000) mentioned in national newspapers, only nine related to medicines.

Conclusions

The PFDs related to medicines are not widely referred to in medical journals or UK national newspapers. By contrast, the Australian and New Zealand National Coronial Information System has contributed cases to 206 publications cited in PubMed, of which 139 are related to medicines. Our search suggests that information from English and Welsh Coroners’ PFDs is under-recognised, even though it should inform public health. The results of inquiries by Coroners and medical examiners worldwide into potentially preventable deaths involving medicines should be used to strengthen the safety of medicines.

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Author information

Authors and Affiliations

  1. Institute of Clinical Sciences, University of Birmingham, Birmingham, B15 2TT, UK

    Robin E. Ferner & Anthony R. Cox

  2. West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham, B18 7QH, UK

    Robin E. Ferner

  3. St Pancras Coroner’s Court, London, N1C 4PP, UK

    Richard Brittain

  4. Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK

    Carl Heneghan, Georgia C. Richards & Jeffrey K. Aronson

Authors
  1. Robin E. Ferner
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  2. Richard Brittain
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  3. Anthony R. Cox
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  4. Carl Heneghan
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  5. Georgia C. Richards
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  6. Jeffrey K. Aronson
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Corresponding author

Correspondence to Robin E. Ferner.

Ethics declarations

Funding

No outside funding was received for the conduct of this study or the preparation of this article.

Conflict of Interest

Richard Brittain is a Coroner, and Robin E. Ferner and Jeffrey K. Aronson have been remunerated for giving advice to Coroners on medicines. Anthony R. Cox, Carl Heneghan and Georgia C. Richards have no conflicts of interest that are directly relevant to the content of this article.

Ethics Approval

This study used only published data and ethics approval was not required.

Consent to Participate

Not applicable.

Consent for Publication

Not applicable.

Data Availability

More data are available at https://preventabledeathstracker.net/.

Code Availability

Code for the Preventable Deaths Tracker is available at https://github.com/georgiarichards/georgiarichards.github.io.

Author Contributions

REF, RB, ARC, CH, GCR and JKA all contributed to the design of the study. JKA and REF undertook the searches. REF and JKA wrote the first draft and all authors contributed to the final draft.

Supplementary Information

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Supplementary file1 (PPTX 533 KB)

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Ferner, R.E., Brittain, R., Cox, A.R. et al. Recognition of Coroners’ Concerns to Prevent Future Deaths from Medicines: A Systematic Review. Pharm Med 37, 357–363 (2023). https://doi.org/10.1007/s40290-023-00486-8

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  • DOI: https://doi.org/10.1007/s40290-023-00486-8

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