Preventable deaths involving opioids in England and Wales, 2013-2022: a systematic case series of coroners’ reports

Background Deaths from opioids have increased in England and Wales, despite recognition of their harms. Coroners’ Prevention of Future Death reports (PFDs) provide important insights that may enable safer use and avert harms, yet these reports involving opioids have not been synthesised. We therefore aimed to identify opioid-related PFDs and explore concerns expressed by coroners to prevent future deaths. Methods In this systematic case series, we screened 3897 coronial PFDs dated between 01 July 2013 and 23 February 2022. These were obtained by web scraping the UK’s Courts and Tribunals Judiciary website to create an openly available database: https://preventabledeathstracker.net/ . PFDs were included when an opioid was implicated in the death. Included PFDs were descriptively analysed, and content analysis was used to assess concerns reported by coroners and responses to such concerns. Findings Opioids were involved in 219 deaths reported by coroners in PFDs (5·6% of all PFDs), equating to 4418 years of life lost (median 33 years/person). Morphine (29%), methadone (23%), and diamorphine (16%) were the most common implicated opioids. Coroners most frequently raised concerns regarding systems and protocols (52%) or safety issues (15%). These concerns were most often addressed to NHS organisations (51%), but response rates were low overall (47%). Interpretation Opioids could be used more safely and appropriately if coroners’ concerns in PFDs were addressed by national organisations such as NHS bodies, government agencies, and policymakers, as well as individual prescribing clinicians. Funding No funding was obtained for this study. The National Institute for Health Research (NIHR) School for Primary Care Research (SCPR) provided funding to establish the Preventable Deaths Tracker website: https://preventabledeathstracker.net/ Research in context Evidence before this study We conducted a systematic search of PubMed and Google Scholar to identify studies of deaths involving opioids in England and Wales and analyses of coroners’ Prevention of Future Death reports (PFDs). We found that deaths from opioids had increased in England and Wales. We also identified studies that have used PFDs to assess preventable deaths during the COVID-19 pandemic and deaths involving anticoagulants, medicines purchased online, medication errors and adverse drug reactions. However, no study to date has examined opioid-related PFDs. Added value of this study We analysed coroners’ concerns in opioid-related deaths for which they issued PFDs and found that on average three decades of life are lost per individual. We found that most opioid-related PFDs involved males (64%) and were caused by prescribed opioids (52%). Deaths involving illicit opioids (24%) were more likely to occur in younger males than deaths from prescribed opioids. Failures in systems and processes were most commonly found to have contributed to preventable opioid-related deaths, but more than half of such concerns remain unaddressed. Implications of all the available evidence Coroners’ PFDs offer important real-world insights into opioid-related deaths and can inform public health strategies that aim to improve the safe use of opioids. Future work should focus on disseminating these findings more widely and engaging with key stakeholders such as NHS organisations and government agencies, so that findings from PFDs can inform guidelines and be implemented in clinical practice.