Preventable deaths involving falls in England and Wales, 2013-2022: a systematic case series of coroners reports
medRxiv (Cold Spring Harbor Laboratory)(2023)
Abstract
Background Falls in older people are common, but can lead to significant harm including death. Coroners in England and Wales have a duty to report cases where action should be taken to prevent deaths, but dissemination of their findings remains poor. Objective To identify preventable fall-related deaths, classify coroners concerns, and explore organisational responses. Design Retrospective case series. Setting Coroners reports to Prevent Future Deaths (PFD) in England and Wales. Methods Web scraping was used to screen and read PFDs from the Courts and Tribunals Judiciary website from July 2013 (inception) to November 2022. Demographic information, coroners concerns and responses from organisations were extracted. Descriptive statistics and content analysis were used to synthesise data. Results 527 PFDs (12.5% of all PFDs) involved a fall that contributed to death. These deaths predominantly affected older people (median 82 years) in the community (72%), with subsequent death in hospital (70.8%). A high proportion of cases experienced fractures, major bleeding or head injury. Coroners frequently raised concerns regarding falls risks assessments, failures in communication, and documentation issues. Only 56.7% of PFDs received a response from the intended recipients. Organisations produced new protocols, improved training, and commenced audits in response to PFDs. Conclusions One in eight preventable deaths reported in England and Wales involved a fall. Addressing concerns raised by coroners should improve falls prevention and care following falls especially for older adults. Poor responses to coroners may indicate that actions are not being taken. Wider learning from PFD findings may help reduce preventable fall-related deaths.
### Competing Interest Statement
KS, CP, JJ, DL, MH, and FD report no interests. 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. HSF has received scholarships (2020-2022) from Brasenose College, University of Oxford and Fidelity National Information Services for undergraduate study.
### Funding Statement
This study did not receive any funding
### Author Declarations
I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.
Yes
The details of the IRB/oversight body that provided approval or exemption for the research described are given below:
The source data is openly available at the Courts and Tribunals Judiciary website (https://www.judiciary.uk)
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).
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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.
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All data produced in the present study are available upon reasonable request to the authors
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Key words
falls,preventable deaths,coroners,wales
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