Preventable deaths from SARS-CoV-2 in England and Wales: a systematic case series of coroners’ reports during the COVID-19 pandemic

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Abstract

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/ .

Article activity feed

  1. SciScore for 10.1101/2021.07.15.21260589: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Ethicsnot detected.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Software and data sharing: We used Python v3.7 in Jupyter Notebooks with pandas, seaborn, and matplotlib libraries to analyse the data.
    Python
    suggested: (IPython, RRID:SCR_001658)
    matplotlib
    suggested: (MatPlotLib, RRID:SCR_008624)

    Results from OddPub: Thank you for sharing your code and data.


    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    There are several limitations to our study. The 23 PFDs included may not represent all preventable deaths caused by COVID-19 and several jurisdictions did not publish any PFDs relating to COVID-19, with no PFDs reported in the North East, East Midlands, South West or Wales. The underreporting of PFDs limits the capacity for actions to be taken to prevent future deaths. However, it is likely that the number of PFDs relating to COVID-19 will increase in the coming months and years owing to the backlog of inquests as well as the time it takes for inquests to conclude and PFDs to be written and uploaded to the Judiciary website. For example, healthcare professionals in England and Wales called for the deaths of their colleagues to be reported to the coroner and for PFDs to be issued15,16. However, we did not identify any PFDs that reported deaths of healthcare professionals. There are also no clear guidelines for when deaths should be reported to the coroner and when PFDs should be issued after inquests, nor any auditing or quality control of these processes. In the meantime, we encourage coroners across England and Wales to continue writing PFDs when they believe deaths could have been prevented so lessons can be learnt from the COVID-19 pandemic. We are also limited by the information reported by coroners in PFDs and we identified missing data in the reports. In 52% of PFDs the age of the deceased was not reported and 26% did not report the date of death. We did not assess comp...

    Results from TrialIdentifier: No clinical trial numbers were referenced.


    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.


    Results from JetFighter: We did not find any issues relating to colormaps.


    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.


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