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Primary care
Preventable deaths from SARS-CoV-2 in England and Wales: a systematic case series of coroners’ reports during the COVID-19 pandemic
  1. Bethan Swift1,2,
  2. Carl Heneghan3,4,
  3. Jeffrey Aronson3,
  4. David Howard5,
  5. Georgia C Richards3,4
  1. 1 Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
  2. 2 Wellcome Trust Centre for Human Genetics, Oxford, UK
  3. 3 Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  4. 4 Global Centre on Healthcare and Urbanisation, University of Oxford, Oxford, UK
  5. 5 Department for Continuing Education, University of Oxford, Oxford, UK
  1. Correspondence to Bethan Swift, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, OX3 9DU, UK; bethan{at}


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 outcome measures 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 ( 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

  • COVID-19
  • public health
  • infectious diseases

Data availability statement

Data are available in a public, open access repository. The data, statistical code and study materials are openly available via the Open Science Framework (OSF) and GitHub.

This article is made freely available for personal use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

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Data availability statement

Data are available in a public, open access repository. The data, statistical code and study materials are openly available via the Open Science Framework (OSF) and GitHub.

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  • Twitter @bethan_swift, @carlheneghan, @JKAronson, @Richards_G_C

  • Contributors GCR developed the idea for this study, wrote the initial study protocol, ran the python code to collect the most recent PFDs for screening, contributed to the first draft of the manuscript and provided supervisory support. BS acts as the guarantor and contributed to the study protocol, screened the 510 PFDs for their eligibility, extracted the data from the 23 included cases, analysed the data and wrote the first draft of the manuscript. CH, JA and DH contributed to the study protocol and supervision of the project. All authors read, reviewed and approved the manuscript prior to submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

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  • Competing interests BS receives funding from Mustafa Bahceci (Bahceci Health Group, Istanbul, Turkey) for her Doctor of Philosophy at the University of Oxford (2019–2022) and has received financial remuneration for consultancy work in women’s health. CH is a National Institute for Health Research (NIHR) Senior Investigator and has received expenses and fees for his media work, received expenses from the WHO, FDA, and holds grant funding from the NIHR School for Primary Care Research (SPCR) and the NIHR SPCR Evidence Synthesis Working Group (Project 380), the NIHR BRC Oxford and the WHO. On occasion, CH receives expenses for teaching EBM and is also paid for his GP work in NHS out of hours (contract with Oxford Health NHS Foundation Trust). JA has published articles and edited textbooks on adverse drug reactions and interactions and has often given medicolegal advice, including appearances as an expert witness in coroners’ courts, often dealing with the adverse effects of opioids and other medicines. DH is the Director of Studies for Sustainable Urban Development at the Department for Continuing Education, University of Oxford. DH has received financial remuneration for providing political and socioeconomic country updates for Latin America and the Caribbean for IHS Global. GCR was financially supported by the NIHR SPCR, the Naji Foundation and the Rotary Foundation to study for a Doctor of Philosophy (2017–2021), but no longer has any financial COIs. GCR is an Associate Editor of BMJ Evidence-Based Medicine and is developing

  • Provenance and peer review Not commissioned; externally peer reviewed.

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