Preventable deaths related to thromboembolism in England and Wales, 2013-2022: A systematic case series of coroners’ reports

Objectives

To identify preventable thromboembolism-related deaths, classify coroner concerns, and explore organisational responses.

Study design

Retrospective systematic case series of coroners’ Prevention of Future Deaths reports (PFDs) from 1 July 2013 to 16 November 2022, in England and Wales.

Methods

Reports were acquired from the Courts and Tribunals Judiciary website and screened for thromboembolism-related deaths using a reproducible automated computer code. Demographic information, coroners’ concerns, and organisational responses to PFDs were extracted and analysed, including risk factors predisposing to thromboembolism.

Results

112 PFDs (2.7 % of all PFDs) involved a thromboembolism event contributing to death. The average age of death was 59 years, corresponding to an estimated median of 25 years of life lost per death. Just over half of deaths occurred in women (52 %). The most common cause of death was pulmonary embolism (85.7 %). Issues with thromboprophylaxis were common, including incorrect risk assessments (27.7 %). Coroners’ concerns most often related to failures in providing adequate care, including communication failures (15.7 %), issues with following protocols and guidelines (11.8 %), and risk assessments (10.8 %). Only 56 % of organisations who were sent a PFD had a published response. When they did respond, the majority of responses reported initiating changes related to improvements to guidelines and protocols, or education and training.

Conclusions

PFDs offer unique insights into the systems and processes leading to preventable thromboembolism-related deaths. Improved awareness and dissemination of PFDs among clinicians and policy-makers, alongside routine monitoring of PFDs, has the potential to improve patient safety and reduce preventable harms from thromboembolic events.