Preventable deaths involving opioids in England and Wales, 2013-2022: a systematic case series of coroners’ reports

Background Deaths from opioids have increased in England and Wales, despite recognition of their harms. Coroners’ Prevention of Future Death reports (PFDs) provide important insights that may enable safer use and avert harms, yet these reports involving opioids have not been synthesised. We therefore aimed to identify opioid-related PFDs and explore concerns expressed by coroners to prevent future deaths. Methods In this systematic case series, we screened 3897 coronial PFDs dated between 01 July 2013 and 23 February 2022. These were obtained by web scraping the UK’s Courts and Tribunals Judiciary website to create an openly available database: . PFDs were included when an opioid was implicated in the death. Included PFDs were descriptively analysed, and content analysis was used to assess concerns reported by coroners and responses to such concerns. Findings Opioids were involved in 219 deaths reported by coroners in PFDs (5·6% of all PFDs), equating to 4418 years of life lost (median 33 years/person). Morphine (29%), methadone (23%), and diamorphine (16%) were the most common implicated opioids. Coroners most frequently raised concerns regarding systems and protocols (52%) or safety issues (15%). These concerns were most often addressed to NHS organisations (51%), but response rates were low overall (47%). Interpretation Opioids could be used more safely and appropriately if coroners’ concerns in PFDs were addressed by national organisations such as NHS bodies, government agencies, and policymakers, as well as individual prescribing clinicians. Funding No funding was obtained for this study. The National Institute for Health Research (NIHR) School for Primary Care Research (SCPR) provided funding to establish the Preventable Deaths Tracker website: Evidence before this study We conducted a systematic search of PubMed and Google Scholar to identify studies of deaths involving opioids in England and Wales and analyses of coroners’ Prevention of Future Death reports (PFDs). We found that deaths from opioids had increased in England and Wales. We also identified studies that have used PFDs to assess preventable deaths during the COVID-19 pandemic and deaths involving anticoagulants, medicines purchased online, medication errors and adverse drug reactions. However, no study to date has examined opioid-related PFDs. Added value of this study We analysed coroners’ concerns in opioid-related deaths for which they issued PFDs and found that on average three decades of life are lost per individual. We found that most opioid-related PFDs involved males (64%) and were caused by prescribed opioids (52%). Deaths involving illicit opioids (24%) were more likely to occur in younger males than deaths from prescribed opioids. Failures in systems and processes were most commonly found to have contributed to preventable opioid-related deaths, but more than half of such concerns remain unaddressed. Implications of all the available evidence Coroners’ PFDs offer important real-world insights into opioid-related deaths and can inform public health strategies that aim to improve the safe use of opioids. Future work should focus on disseminating these findings more widely and engaging with key stakeholders such as NHS organisations and government agencies, so that findings from PFDs can inform guidelines and be implemented in clinical practice. ### Competing Interest Statement FD is employed as a Foundation Doctor in the National Health Service (NHS). ETT is funded by the Clarendon Fund to study for a Doctor of Philosophy (DPhil) at the University of Oxford (2020-23). MB has no interests to declare. NJD is supported by a studentship from the Naji Foundation and a grant from the Fetzer Franklin Memorial Fund. HSF has received scholarships (2020-22) from Brasenose College, University of Oxford, and Fidelity National Information Services for undergraduate study, from the British Pharmacological Society (2022) for meritorious performance in a research competition and received payments (2022) from Brasenose College, University of Oxford for undergraduate teaching. REF has undertaken research and published on adverse drug reactions and medication errors and has acted as an expert witness in coronial and other legal cases related to these. ARC holds grant funding from Cancer Alliance. ARC has received fees for media work, a scientific advisory committee at IQVIA, and external examining at UK Universities. ARC is the Head of the School of Pharmacy at the University of Birmingham and is an honorary pharmacovigilance pharmacist at the West Midlands Centre for Adverse Drug Reaction Reporting. CH holds grant funding from the NIHR, the NIHR School of Primary Care Research. CH has received expenses and fees for his media work, for teaching EBM and is also paid for his GP work in NHS out of hours (contract Oxford Health NHS Foundation Trust). CH is the Director of the Centre for Evidence-based Medicine (CEBM). JKA has published papers in bioscience journals and edited textbooks on adverse drug reactions; he has often acted as an expert witness in civil actions relating to suspected adverse drug reactions and in coroners courts. GCR is the Director of a limited company that is independently contracted to work as an Epidemiologist and teach at the University of Oxford. GCR received scholarships (2017-2020) from the NHS National Institute of Health Research (NIHR) School for Primary Care Research (SPCR), the Naji Foundation, and the Rotary Foundation to study for a DPhil at the University of Oxford. ### Clinical Protocols ### Funding Statement No funding was obtained for this study. An Engagement and Dissemination grant (2020) and Seedcorn funding (2021) were obtained from the National Institute of Health Research (NIHR) School for Primary Care Research (SPCR) to develop the Preventable Deaths Tracker website: https://preventabledeathstracker.net/ ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes All study materials, data, and statistical code are openly available via online repositories. The study protocol was preregistered on the Open Science Framework (OSF; ); the code to generate the database and the Preventable Deaths Tracker is openly available via GitHub (); individual Prevention of Future Deaths reports are available on the Courts and Tribunals Judiciary website (); all other study materials are openly available via the OSF project page ().