A thematic analysis of National Institute for Health and Care Excellence responses to coroners’ concerns’

In England and Wales, law requires that coroners issue a Prevention of Future Death (PFD) report when they believe that action should be taken to prevent future deaths. Prevention of Future Death reports therefore provide an opportunity to learn and prevent harm. This study thematically analyses PFD reports received by the National Institute for Health and Care Excellence (NICE) along with the organisation's response. We undertook a framework analysis of PFD reports, the organisation's response, and supporting documents or correspondence. Our framework was developed with a deductive approach, with themes pre-selected using areas of interest to the inquiry, including NHS England's national standards for patient safety investigation. The review includes 39 reports dated from 2012 to 2020. Common health areas involved were intrapartum care and head injuries. Coroners frequently raised the issue of a lack of relevant NICE guidance, with NICE most often committing to reflecting on the issues raised through its established processes. Recent responses demonstrated greater consideration of implementation and engagement actions, along with a more collaborative approach and person-centred tone. This report provides insight into the PFD report practices of a national guidance producing and standard setting body in the UK. The report supports system-level understanding of current practices in relation to PFD reports. However, there are no means to assess if the Chief Coroner's Office and the wider safety system considered them an adequate response or whether the actions taken were effective. Recommendations are made to support transparency, learning and collaboration in an evolving patient safety landscape.