Preventable deaths from SARS-CoV-2 in England and Wales: a systematic case series of coroners’ reports during the COVID-19 pandemic (21 December 2021)

Summary

This study in BMJ Evidence-Based Medicine examined coroners’ Prevention of Future Deaths (PFDs) reports to identify deaths involving Covid-19 that coroners saw as preventable.

The authors found that:

• there was geographical variation in the reporting of PFDs; most (39%) were written by coroners in the North West of England.
• the coroners raised 56 concerns, problems in communication being the most common (30%), followed by failure to follow protocols (23%).
• NHS organisations were sent the most PFDs (51%), followed by the government (26%). 
• responses to PFDs by these organisations were poor.

The study concludes that PFDs contain a rich source of information on preventable deaths that has previously been difficult to examine systematically. It identified concerns raised by coroners that need to be addressed during the government’s inquiry into the handling of the Covid-19 pandemic, to reduce the likelihood of mistakes being repeated.