Preventable suicides involving medicines before the covid-19 pandemic: a systematic case series of coroners’ reports in England and Wales

Background Over 5000 suicides are registered in England and Wales each year. Coroners’ Prevention of Future Deaths reports (PFDs) share concerns to promote actions to reduce the risks of similar deaths. Aims To systematically review coroners’ PFDs involving suicides in which a medicine caused or contributed to the death, to identify lessons for suicide prevention. Methods 3037 PFDs were screened for eligibility between July 2013 and December 2019. Following data extraction, descriptive statistics and content analysis were performed to assess coroners’ concerns, the recipients, and the response rates to reports. Results There were 734 suicide-related PFDs, with 100 reporting a medicine. Opioids (40%) were the most common class involved in suicide-related PFDs, followed by antidepressants (30%). There was wide geographical variation in the writing of PFDs; coroners in Manchester wrote the most (18%). Coroners expressed 237 concerns; the most common were procedural inadequacies (14%, n=32), inadequate documentation and communication (10%, n=22), and inappropriate prescription access (9%, n=21). 203 recipients received these PFDs, most being sent to NHS trusts (31%), clinical commissioning groups (10%), and general practices (10%), of which only 58% responded to the coroner. Conclusions Concerns raised by coroners in suicide-related PFDs involving medicines highlight essential gaps in care that require actions from the Government, health services, and prescribers. To aid suicide prevention, PFDs should be disseminated nationally, and responses should be enforced so that actions are taken to prevent suicides. Study protocol registration: https://doi.org/10.17605/OSF.IO/EXJK3