Footnotes

• Twitter @_ETThomas, @Richards_G_C

• Contributors ETT devised the idea for this article, identified the coroner’s report and wrote the first draft of the manuscript. GCR also devised the idea for this article, analysed and presented the data on reports to the Medicines and Healthcare products Regulatory Agency Yellow Card Scheme, and contributed to drafting and editing the manuscript.

• 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.

• Competing interests ETT is financially supported by a University of Oxford Clarendon Scholarship to study for the degree of Doctor of Philosophy (DPhil/PhD). GCR is financially supported by the National Institute of Health Research (NIHR) School for Primary Care Research, the Naji Foundation and the Rotary Foundation to study for the degree of Doctor of Philosophy (DPhil/PhD). GCR is an editorial registrar of BMJ Evidence Based Medicine and is developing the https://preventabledeathstracker.net/ website. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health and Social Care.

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