Recognition of coroners’ concerns to prevent future deaths from medicines: a systematic review

<p><strong>Background:</strong>&nbsp;Coroners, who hold inquests to determine the causes of unnatural deaths in England and Wales, having recognised factors that could cause other deaths, are legally obliged to signal concerns by sending &lsquo;Reports to Prevent Future Dea...

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Main Authors: Ferner, RE, Brittain, R, Cox, AR, Heneghan, C, Richards, GC, Aronson, JK
Format: Journal article
Language:English
Published: Springer 2023
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author Ferner, RE
Brittain, R
Cox, AR
Heneghan, C
Richards, GC
Aronson, JK
author_facet Ferner, RE
Brittain, R
Cox, AR
Heneghan, C
Richards, GC
Aronson, JK
author_sort Ferner, RE
collection OXFORD
description <p><strong>Background:</strong>&nbsp;Coroners, who hold inquests to determine the causes of unnatural deaths in England and Wales, having recognised factors that could cause other deaths, are legally obliged to signal concerns by sending &lsquo;Reports to Prevent Future Deaths&rsquo; (PFDs) to interested persons. We aimed to establish whether Coroners&rsquo; concerns about medications are widely recognised.</p> <p><strong>Methods:</strong>&nbsp;We searched MEDLINE, Embase and Web of Science up to 30 November, 2022 for publications linking PFDs and medications using a combination of search terms &ldquo;coroner*&rdquo;, &ldquo;inquest*&rdquo;, &ldquo;medicine*&rdquo;, &ldquo;medication*&rdquo; and &ldquo;prevent*&rdquo;. We also searched the&nbsp;<em>BMJ</em>, a UK journal that carries news items; and the databases Nexis Advance and News On the Web for reports in national newspapers between 2013 and 2022, using the search terms (&ldquo;regulation 28&rdquo; OR &ldquo;prevent future deaths&rdquo; OR &ldquo;prevention of future deaths&rdquo;) AND &ldquo;coroner&rdquo;. We recorded the number of publications, as well as their citations in Google Scholar at 23 May, 2023.</p> <p><strong>Results:</strong>&nbsp;Only 11 published papers on medicines referenced UK PFDs, nine of which were from our group. The&nbsp;<em>BMJ</em>&nbsp;carried 23 articles mentioning PFDs, five related to medicines. Of 139 PFDs (out of over 4000) mentioned in national newspapers, only nine related to medicines.</p> <p><strong>Conclusions:</strong>&nbsp;The PFDs related to medicines are not widely referred to in medical journals or UK national newspapers. By contrast, the Australian and New Zealand National Coronial Information System has contributed cases to 206 publications cited in PubMed, of which 139 are related to medicines. Our search suggests that information from English and Welsh Coroners&rsquo; PFDs is under-recognised, even though it should inform public health. The results of inquiries by Coroners and medical examiners worldwide into potentially preventable deaths involving medicines should be used to strengthen the safety of medicines.</p>
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spelling oxford-uuid:d7caffa7-1378-445e-bbf6-9780b177cec32024-05-15T16:25:54ZRecognition of coroners’ concerns to prevent future deaths from medicines: a systematic reviewJournal articlehttp://purl.org/coar/resource_type/c_dcae04bcuuid:d7caffa7-1378-445e-bbf6-9780b177cec3EnglishSymplectic ElementsSpringer2023Ferner, REBrittain, RCox, ARHeneghan, CRichards, GCAronson, JK<p><strong>Background:</strong>&nbsp;Coroners, who hold inquests to determine the causes of unnatural deaths in England and Wales, having recognised factors that could cause other deaths, are legally obliged to signal concerns by sending &lsquo;Reports to Prevent Future Deaths&rsquo; (PFDs) to interested persons. We aimed to establish whether Coroners&rsquo; concerns about medications are widely recognised.</p> <p><strong>Methods:</strong>&nbsp;We searched MEDLINE, Embase and Web of Science up to 30 November, 2022 for publications linking PFDs and medications using a combination of search terms &ldquo;coroner*&rdquo;, &ldquo;inquest*&rdquo;, &ldquo;medicine*&rdquo;, &ldquo;medication*&rdquo; and &ldquo;prevent*&rdquo;. We also searched the&nbsp;<em>BMJ</em>, a UK journal that carries news items; and the databases Nexis Advance and News On the Web for reports in national newspapers between 2013 and 2022, using the search terms (&ldquo;regulation 28&rdquo; OR &ldquo;prevent future deaths&rdquo; OR &ldquo;prevention of future deaths&rdquo;) AND &ldquo;coroner&rdquo;. We recorded the number of publications, as well as their citations in Google Scholar at 23 May, 2023.</p> <p><strong>Results:</strong>&nbsp;Only 11 published papers on medicines referenced UK PFDs, nine of which were from our group. The&nbsp;<em>BMJ</em>&nbsp;carried 23 articles mentioning PFDs, five related to medicines. Of 139 PFDs (out of over 4000) mentioned in national newspapers, only nine related to medicines.</p> <p><strong>Conclusions:</strong>&nbsp;The PFDs related to medicines are not widely referred to in medical journals or UK national newspapers. By contrast, the Australian and New Zealand National Coronial Information System has contributed cases to 206 publications cited in PubMed, of which 139 are related to medicines. Our search suggests that information from English and Welsh Coroners&rsquo; PFDs is under-recognised, even though it should inform public health. The results of inquiries by Coroners and medical examiners worldwide into potentially preventable deaths involving medicines should be used to strengthen the safety of medicines.</p>
spellingShingle Ferner, RE
Brittain, R
Cox, AR
Heneghan, C
Richards, GC
Aronson, JK
Recognition of coroners’ concerns to prevent future deaths from medicines: a systematic review
title Recognition of coroners’ concerns to prevent future deaths from medicines: a systematic review
title_full Recognition of coroners’ concerns to prevent future deaths from medicines: a systematic review
title_fullStr Recognition of coroners’ concerns to prevent future deaths from medicines: a systematic review
title_full_unstemmed Recognition of coroners’ concerns to prevent future deaths from medicines: a systematic review
title_short Recognition of coroners’ concerns to prevent future deaths from medicines: a systematic review
title_sort recognition of coroners concerns to prevent future deaths from medicines a systematic review
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