Table 1

Summary of 23 deaths involving SARS-CoV-2 as reported in Prevention of Future Deaths (PFDs) reportsin England and Wales between 1 January 2020 and 28 June 2021, ordered by causes and date of death (created by the authors)

AgeSexDatesCauses of deathResponses to PFDs
DeathInquestReportAddressee(s)Date of reply*
Directly related to COVID-19
–M13 Apr 202014 Apr 202001 Dec 2020

  1. Community-acquired pneumonia

  2. COVID-19

  3. Dementia, chronic obstructive pulmonary disease, asbestos-related pulmonary fibrosis, pleural plaques, type 2 diabetes

  1. CQC

  2. Vicarage Residential Care Home

  3. Public Health England

  4. NHS England

  5. Greater Manchester Health and Social Care Partnership

  1. 04 Feb 2021

  2. Undated

  3. 26 Jan 2021

  4. 02 Mar 2021

  5. 19 Feb 2021

86F17 Apr 202003 Jul 202011 Dec 2020Natural causes and COVID-19Whipps Cross HospitalReceived but not dated
74M21 Apr 202022 Apr 202001 Dec 2020

  1. Hypovolemic shock

  2. End-stage kidney disease

  3. Polyneuropathy, frailty and COVID-19

  1. Department of Health and Social Care

  2. Royal London Hospital

Not yet received†
–M21 May 202026 May 202009 Dec 2020

  1. COVID-19 pneumonia

  2. Right-sided neck of femur fracture, hypertension, atrial fibrillation

  1. Public Health England

  2. NHS England

  1. 11 Feb 2021

  2. 09 Feb 2021

18M31 Jul 202003 Aug 202030 Mar 2021Drowning to which COVID-19 and asthma were contributory

  1. Craven District Council

  2. Yorkshire Dales National Park

  3. Yorkshire Water

Not yet received†
–M07 Sep 202007 Sep 202024 Apr 2021

  1. Bronchopneumonia in combination with COVID-19

  2. Falls with vertebral fractures, type 2 diabetes mellitus, pulmonary fibrosis, heart failure and epilepsy

  1. Greater Manchester Health and Social Care Partnership

  2. NHS England

  1. 07 Sep 2021

  2. 02 Jul 2021

–M15 Nov 202016 Nov 202011 Jun 2021

  1. COVID-19 pneumonitis

  2. Chronic obstructive pulmonary disease, ischaemic heart disease, previous right upper lobe resection for lung adenocarcinoma, type 2 diabetes mellitus

Tameside CCG24 Jun 2021
90M28 Jan 202108 Feb 202123 Apr 2021

  1. COVID-19 pneumonia

  2. Dementia, heart failure, acute on chronic subdural haematoma, fall

Medway Maritime Hospital07 Jun 2021
–M05 Feb 202108 Feb 202110 Jun 2021

  1. COVID-19 on background of immunomodulatory treatment

  2. Seborrheic eczema

  3. Peripheral vascular disease

  1. NHS England

  2. Secretary of State of Health

Not yet received†
–M14 November 202017 Nov 202014 Jun 2021

  1. Aspiration pneumonia on a background of a choking incident, COVID-19 pneumonitis

  2. Alzheimer’s dementia

  1. MHRA

  2. NHS Stockport CCG

  1. 27 Jul 2021

  2. 06 Aug 2021

–M–30 Oct 202019 Feb 2021COVID-19 pneumonitis

  1. Brighton Sussex University NHS Hospital Trust

  2. West Sussex NHS Hospital Trust

  3. Medicolegal

  1. 19 Mar 2021

  2. Not yet received†

  3. Not yet received†

Indirectly related to COVID-19
32F19 Mar 202030 Mar 202023 Nov 2020

  1. Hanging

  2. Bipolar affective disorder

  1. Sussex Partnership Foundation NHS Trust

  2. Brighton and Hove City Council

  1. 10 Feb 2021

  2. 10 Feb 2021

–M17 Apr 202024 Apr 202007 Dec 2020Methadone toxicity

  1. Public Health England

  2. Haverhill Pharmacy

  1. 13 Jan 2021

  2. Undated

–M24 Apr 202005 May 202019 Nov 2020Suicide

  1. Woolwich Station Medical Centre

  2. Ministry of Defence

  1. Not received†

  2. 16 Feb 2021

–F20 Jun 202023 Jun 202011 Feb 2021

  1. Bronchopneumonia

  2. Frailty

  3. Dementia

  4. Hypertension

  5. Fractured neck of femur

  1. CQC

  2. Department of Health and Social Care

  1. 04 Jun 2021

  2. 03 Jun 2021

28M10 Aug 202014 Aug 202015 Mar 2021SuicideSussex Partnership NHS Foundation TrustNot yet received†
76F28 Sep 202003 Dec 202016 Dec 2020Atherosclerosis and complete blockage of one artery

  1. NHS Pathways‡

  2. COVID-19 Pandemic Response Service

10 Feb 2021
–M25 Oct 202026 Oct 202002 Jun 2021Combined drug toxicologyStockport CCG07 Jul 2021
77M–08 Oct 202002 Feb 2021

  1. Advanced dementia

  2. Fractured neck of femur

  3. Ischaemic heart disease

  1. Adult Social Services, Norfolk County Council

  2. Norfolk and Norwich University Hospital

  1. 11 Mar 2021

  2. 09 Apr 2021

88M–20 Aug 202005 Feb 2021

  1. Bronchopneumonia

  2. Heat stroke

  3. Dehydration

Care Outlook18 Apr 2021
–M–11 Aug 202007 May 2021

  1. Small bowel obstruction and perforation

  2. Ingestion of foreign body

Norfolk and Norwich University Hospital NHS Foundation Trust23 Jul 2021
68F–20 Sep 202014 Dec 2020

  1. Pneumothorax

  2. Rib fractures

  3. Fall

  4. Chronic obstructive pulmonary disease and ischaemic heart disease

West Midlands Ambulance Service08 Jan 2021
87M–08 Oct 202007 May 2021

  1. Urosepsis

  2. Long-term indwelling catheter not changed since October 2019

  3. Alzheimer’s dementia, cerebrovascular accident, chronic kidney disease, bladder cancer, prostate cancer

Lower Clapton Group Practice24 Jun 2021

  • Deaths directly related were defined as those that the coroner explicitly reported COVID-19 as a cause of death or a positive test for COVID-19 within 28 days of death. Indirectly related deaths were defined as those that were attributed to mitigation measures during the COVID-19 pandemic.

  • *Recipients of PFDs have 56 days from the date of report to respond to the coroner under Regulation 29 of the Coroners (Investigations) Regulations 2013.

  • †Replies were still overdue on 18 Oct 2021; however not all replies are posted on the Judiciary website.

  • ‡NHS Digital responded on behalf of NHS Pathways and the COVID-19 Pandemic Response Service.

  • CCG, Clinical Commissioning Group; CQC, Care Quality Commission; MHRA, Medicines and Healthcare products Regulatory Agency; NHS, National Health Service.