Deaths from medicines: lessons from coroners’ reports are too easily lost, review finds

Coroners’ reports often do not fulfil their statutory aim to prevent future deaths in the case of fatalities related to medicines, a report suggests.1

The researchers, led by Robin Ferner of the West Midlands Centre for Adverse Drug Reactions, said that alerting national rather than local organisations to the reports would ensure that important lessons about patient safety would be learnt.

The law in England and Wales requires coroners to write “regulation 28” reports to the appropriate bodies if an inquest reveals information that could be used to prevent future deaths. The report outlines the coroner’s recommendations for action and requires a response from the body within 56 days, outlining the steps to be taken.

The researchers found that reports of national importance were usually sent only to local bodies, in contrast with coroners’ reports in New Zealand, which are widely disseminated. Despite calls for more openness to help boost patient safety many organisations did not publish their responses, and the researchers met resistance when they used Freedom of Information Act requests to try to obtain responses.

In addition, said the authors, “there appears to be no system for auditing concerns and responses to them. So, it is difficult to know whether—with regards to medicines—the coronial system prevents future death. Only a minority of the responses that we analysed appear to provide robust and generally applicable ways to prevent future deaths.”

Ferner and colleagues analysed 99 coroners’ reports, covering 100 deaths. Reports were sent to a wide range of bodies including prisons, hospitals, care homes, government agencies or departments, and drug companies. The reports are published on the UK judiciary website, but only a third of responses appeared on it.

The study notes that unsafe practices can go unrecognised for years in the NHS, putting further lives at risk. It cites poor prescribing and use of opiates at Gosport War Memorial Hospital, which led to premature deaths. The inquiry into the Gosport deaths found that the coroner had not issued a report under rule 43, the forerunner to regulation 28.

In some cases local solutions were proposed to solve problems of communication, monitoring, and timeliness of drug administration that would have been of national relevance, the researchers concluded. “Sometimes, as when codeine was banned from surgical wards to prevent prescription of the drug to patients with renal impairment, proposed solutions failed to tackle the underlying general problem that drugs are sometimes prescribed to patients in whom they are contraindicated,” they wrote.

If coroners’ reports were routinely addressed to national bodies such as NHS Improvement, the Care Quality Commission, or the Medicines and Healthcare Products Regulatory Agency, the researchers suggested, “important information to prevent future deaths would be available to the whole NHS and lessons less easily forgotten.”