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Coroners’ concerns to prevent harms: a series of coroners’ case reports to serve patient safety and educate the public, clinicians and policy-makers

© Author(s) (or their employer(s)) 2020. No commercial reuse. See rights and permissions. Published by BMJ. Understanding the causes of deaths and how they can be prevented is critical for improving healthcare outcomes. At a population level, overreporting or underreporting of deaths can have a profound impact on policy decisions, which in turn affect global economies and the daytoday lives of citizens. At the individual level, understanding how and why deaths occur may prevent similar deaths or serious harms from occurring in the future. One in 20 people are exposed to preventable harms in medical settings globally, and 12% of preventable harms result in disability or death. Coroners’ reports hold a wealth of information on the circumstances of individual deaths. In England and Wales, the law requires coroners to report and communicate a death when the coroner believes that action should be taken to prevent deaths. These reports, named Prevent Future Deaths (PFDs), are mandated under paragraph 7 of schedule 5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 4 Under these regulations, individuals or organisations that receive a PFD report are required under statue to respond to the coroner within 56 days of receiving the report, to outline actions proposed or taken to address the coroner’s concerns. The Courts and Tribunals Judiciary website hosts the PFD reports and responses to the reports. As these reports contain valuable lessons, concerns have been raised regarding the lack of dissemination and communication of these lessons. Alerting national rather than local organisations about the lessons from these deaths has been one recommendation for serving patient safety initiatives in the National Health Service (NHS). However, the lessons from these deaths are farreaching, and not just applicable to the NHS. Thus, we launch this new series in order to identify relevant case reports that have important lessons for the public and professional communities, and the potential to prevent similar deaths. Although coroners’ reports are concerned with deaths, they contain lessons that may help in preventing nonfatal harms as well, and so we include those in our purview, and title our series, ‘Coroners’ Concerns to Prevent Harms’.