A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): a tool for patient safety in hospitals.
Bremner BT, Heneghan CJ, Aronson JK, et al. A systematic narrative review of coroners’ Prevention of Future Deaths reports (PFDs): a tool for patient safety in hospitals. J Patient Saf Risk Manag. 2023;28(5):227-236. doi:10.1177/25160435231198685.
Autopsies and coronial investigations provide important learning opportunities. In the UK, coroners may issue Prevention of Future Death reports (PFD) when they determine taking actions could prevent future deaths. This review summarizes studies that use PFDs to investigate patient safety, such as medication- or diagnosis-related deaths. The authors conclude the impact of PFDs could be strengthened by improving the reporting and dissemination system and enforcing the requirement that hospitals submit a response.