RT Journal Article SR Electronic T1 Preventable deaths from SARS-CoV-2 in England and Wales: a systematic case series of coroners’ reports during the COVID-19 pandemic JF BMJ Evidence-Based Medicine JO BMJ EBM FD BMJ Publishing Group Ltd SP 296 OP 304 DO 10.1136/bmjebm-2021-111834 VO 27 IS 5 A1 Bethan Swift A1 Carl Heneghan A1 Jeffrey Aronson A1 David Howard A1 Georgia C Richards YR 2022 UL http://ebm.bmj.com/content/27/5/296.abstract AB 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 (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/.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.