Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
Wellcome Trust Centre for Human Genetics, Oxford, UK.
BMJ Evid Based Med. 2022 Oct;27(5):296-304. doi: 10.1136/bmjebm-2021-111834. Epub 2021 Dec 21.
To examine coroners' Prevention of Future Deaths (PFDs) reports to identify deaths involving SARS-CoV-2 that coroners deemed preventable.
Consecutive case series.
England and Wales.
Patients reported in 510 PFDs dated between 01 January 2020 and 28 June 2021, collected from the UK's Courts and Tribunals Judiciary website using web scraping to create an openly available database: https://preventabledeathstrackernet/.
Concerns reported by coroners.
SARS-CoV-2 was involved in 23 deaths reported by coroners in PFDs. Twelve deaths were indirectly related to the COVID-19 pandemic, defined as those that were not medically caused by SARS-CoV-2, but were associated with mitigation measures. In 11 cases, the coroner explicitly reported that COVID-19 had directly caused death. There was geographical variation in the reporting of PFDs; most (39%) were written by coroners in the North West of England. The coroners raised 56 concerns, problems in communication being the most common (30%), followed by failure to follow protocols (23%). Organisations in the National Health Service were sent the most PFDs (51%), followed by the government (26%), but responses to PFDs by these organisations were poor.
PFDs contain a rich source of information on preventable deaths that has previously been difficult to examine systematically. Our openly available tool (https://preventabledeathstracker.net/) streamlines this process and has identified many concerns raised by coroners that should be addressed during the government's inquiry into the handling of the COVID-19 pandemic, so that mistakes made are less likely to be repeated. STUDY PROTOCOL PREREGISTRATION: https://osf.io/bfypc/.
通过审查验尸官的《预防未来死亡报告》（PFD），确定验尸官认为可预防的与 SARS-CoV-2 相关的死亡案例。
连续病例系列。
英格兰和威尔士。
从英国法院和法庭司法网站上使用网络爬虫收集的 510 份 PFD 报告中提取了 2020 年 1 月 1 日至 2021 年 6 月 28 日期间报告的患者，创建了一个公开可用的数据库：https://preventabledeathstrackernet/。
验尸官报告的关注点。
在 PFD 报告中，有 23 例死亡与 SARS-CoV-2 有关。其中 12 例死亡与 COVID-19 大流行间接相关，定义为并非由 SARS-CoV-2 直接引起的医疗原因，但与缓解措施有关。在 11 例案例中，验尸官明确报告 COVID-19 直接导致了死亡。在报告 PFD 方面存在地域差异；其中，来自英格兰西北部的验尸官报告的案例最多（39%）。验尸官提出了 56 项关注，其中沟通问题最为常见（30%），其次是未遵循协议（23%）。国家卫生服务组织收到的 PFD 最多（51%），其次是政府（26%），但这些组织对 PFD 的回应很差。
PFD 包含了有关可预防死亡的丰富信息，这些信息以前很难系统地进行检查。我们公开的工具（https://preventabledeathstracker.net/）简化了这一过程，并确定了验尸官提出的许多关注点，这些关注点应在政府对 COVID-19 大流行处理情况的调查中得到解决，以避免重蹈覆辙。研究方案预先注册：https://osf.io/bfypc/。
