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A thematic analysis of Prevention of Future Deaths reports

A study, conducted by Leary et al, has looked into whether any data from a patient safety perspective can be extracted from Prevention of Future Deaths (PFD) reports issued pursuant to Regulation 28 of the Coroners (Investigations) Regulations 2013.

The study looked for any potential common themes from the recommendations issued. PFD reports from 2016 to 2019 for deaths in hospitals, care homes and the community were investigated.

The study analysed 710 PFD reports that met the study’s inclusion criteria. The majority of PFD reports related to hospital deaths, in respect of which the mean number of concerns per report was 4.7.

Five primary common themes were identified in PFD reports over this period:

  • A deficit in skill or knowledge
  • Missed, delayed or uncoordinated care
  • Communication and cultural issues
  • Systems issues
  • Lack of resources

98% of the reports involved more than one concern across the different themes. A major theme from the cases analysed was “poor or no coordination of care.” The study includes case examples.

The themes emerging from the study may provide a framework for learning and quality improvement. The study’s recurring themes of “Uncoordinated, delayed or unplanned care, deficits in knowledge and lack of resources” evidence the potential risks associated with a deficit in the workforce, whether based on numbers or skill. The study also noted 24 reports which focused on NEWS and incorrect, inappropriate or non-existent use of the scale, evidencing the risks associated with the reliance on “dilution of frontline expertise” as a mechanism to meet demand.

36 reports expressed concerns over repeat PFD reports being issued to the same Trust/organisation. The study emphasises that were PFD reports to be used as a source of data, they could act as an early warning system to avoid future deaths.

There was also some correlation between the themes identified in this study and a separate study regarding non-fatal incident reporting. It is suggested that it may be possible to interrogate incident reports to improve patient safety.

For further detail on the study please click here.

For further assistance on this matter, please get in touch.

Please note that this briefing is designed to be informative, not advisory and represents our understanding of English law and practice as at the date indicated. We would always recommend that you should seek specific guidance on any particular legal issue.

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