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

As of June 2021, 12% of global deaths attributed to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have occurred in England and Wales. Examining Coroners Prevention of Future Deaths reports (PFDs) between March 2020 and 28 June 2021 in England and Wales, we found 23 cases (4.5% of PFDs) involving SARS-CoV-2, with 52% (n=12) of deaths indirectly- and 48% directly-related. There was geographical variation with most (39%) PFDs written by coroners in the North-West of England. Fifty-six concerns were raised by coroners with problems in communication being the most (30%) repeated concern, followed by a failure to follow protocols (23%). Organisations in the National Health Services (NHS) received the most PFDs (51%), followed by the government (26%). Policymakers should consider an intermediate step prior to PFDs to ensure lessons from the COVID-19 pandemic are rapidly identified. In the meantime, PFDs should be used to prevent future deaths.

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