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
; 27(5): 296-304, 2022 10.
Article
in English
| MEDLINE | ID: covidwho-1583130
ABSTRACT
OBJECTIVES:
To examine coroners' Prevention of Future Deaths (PFDs) reports to identify deaths involving SARS-CoV-2 that coroners deemed preventable.DESIGN:
Consecutive case series.SETTING:
England and Wales.PARTICIPANTS:
Patients reported in 510 PFDs dated between 01 January 2020 and 28 June 2021, collected from the UK's Courts and Tribunals Judiciary website using web scraping to create an openly available database https//preventabledeathstrackernet/. MAIN OUTCOMEMEASURES:
Concerns reported by coroners.RESULTS:
SARS-CoV-2 was involved in 23 deaths reported by coroners in PFDs. Twelve deaths were indirectly related to the COVID-19 pandemic, defined as those that were not medically caused by SARS-CoV-2, but were associated with mitigation measures. In 11 cases, the coroner explicitly reported that COVID-19 had directly caused death. 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%). Organisations in the National Health Service were sent the most PFDs (51%), followed by the government (26%), but responses to PFDs by these organisations were poor.CONCLUSIONS:
PFDs contain a rich source of information on preventable deaths that has previously been difficult to examine systematically. Our openly available tool (https//preventabledeathstracker.net/) streamlines this process and has identified many concerns raised by coroners that should be addressed during the government's inquiry into the handling of the COVID-19 pandemic, so that mistakes made are less likely to be repeated. STUDY PROTOCOL PREREGISTRATION https//osf.io/bfypc/.Keywords
Full text:
Available
Collection:
International databases
Database:
MEDLINE
Main subject:
Coroners and Medical Examiners
/
COVID-19
Type of study:
Observational study
/
Prognostic study
/
Systematic review/Meta Analysis
Limits:
Humans
Country/Region as subject:
Europa
Language:
English
Journal:
BMJ Evid Based Med
Year:
2022
Document Type:
Article
Affiliation country:
Bmjebm-2021-111834
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