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Thematic analysis of ‘Prevention of Future Deaths’ reports related to emergency departments in England and Wales 2013–2022
  1. Sarah Hodgson1,
  2. Keiran O'Mahony2,
  3. James Nicholson3,4,
  4. Pete Williams2
  1. 1 Emergency Department, Raigmore Hospital, Inverness, UK
  2. 2 Emergency Department, Ysbyty Gwynedd, Bangor, UK
  3. 3 Highland Medical Education Centre, Raigmore Hospital, Inverness, UK
  4. 4 Resuscitation Research Group, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
  1. Correspondence to Dr Sarah Hodgson, Emergency Department, Raigmore Hospital, Inverness, IV2 3UJ, UK; sarah.hodgson2{at}

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Since 2013, coroners in England and Wales have issued ‘Prevention of Future Deaths’ (PFD) reports to individuals or organisations if, following an inquest, they believe action should be taken to prevent further avoidable deaths. The Chief Coroner’s annual report details the operation of the coroner’s service and does not collate PFD findings.1 By contrast, Australia’s coronial system collates all inquest findings, informing injury prevention and health-professional education.

Analysis of three years of PFD reports highlighted their potential to inform healthcare policy.2 However, a study of 150 reports found limited impact on practice,3 reflecting concerns that findings are often directed to local organisations and not disseminated nationally.4

We identified and analysed PFD reports relating to emergency departments (EDs), aiming to identify common themes in coroners’ concerns.

Using the Judiciary (England and Wales) website, 2277 unique reports were extracted for July 2013 to December 2022, across three relevant categories (‘community healthcare’, ‘emergency services’ and ‘hospital’ related-deaths).1 These were screened to select reports where the coroner referenced care …

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  • Handling editor Aileen McCabe

  • Contributors PW responsible for research idea and contributed to data interpretation. SH and KOM responsible for data acquisition and initial data analysis. JN and SH responsible for subanalyses. Data tables and figures by JN. Manuscript written by SH and JN and reviewed by KOM and PW.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.