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The number of preventable deaths registered in the UK caused by failing public services doubled last year, Byline Times can reveal.
Preventable death (PfD) orders are the most serious ruling coroner’s courts can make and are issued to highlight serious failings – usually by government or state-run services – that may have caused or contributed to someone’s premature death.
The orders are issued to help prevent future fatalities from causes uncovered during inquests and often contain advice on changing procedures and safety rules, or to highlight services struggling to meet their obligations.
Recent figures show preventable deaths were most common in medical settings, with the number of avoidable deaths recorded by coroners involving hospitals or emergency services almost doubling since the previous year.
In cases logged as involving hospital deaths or emergency service provision, the cases increased from 129 rulings in the 2022-2023 financial year to 240 in the 2023-2024 financial year. Cases included 13-hour ambulance delays leading to patient deaths and a shortage of mental hospital beds leading to a 15-year-old’s suicide.
EveryDoctor Chief Executive, Dr Julia Patterson, told Byline Times that the government has “profoundly failed” the NHS which is now in a “state of emergency”.
Department of Health Sets Aside £21 Billion for Negligence Cases – But Has No Idea if Situation is Getting Better or Worse
A new report has found the ministry spends £3 billion a year on maternity services but paid out an ‘eye-watering’ £1.1 billion in claims for 2022-23
“For the last few years, we have heard countless incidents of NHS doctors working in suboptimal conditions, because of the relentless pressure facing the NHS and the lack of attention and investment from the Conservative government. Politicians have profoundly failed both NHS patients and the staff who are dedicated to keeping them safe, and whichever new government forms in July will need to swiftly reverse this situation.”
These recommendations (PfD orders) are made and then kind of just collect dust. And there’s no one that oversees that or ensures that there’s follow-ups taken up
Aniesha Obuobie, Grenfell Project and Inquest
The grim hospital figures come weeks after Byline Times revealed that the Department of Health and Social Care has set aside £21 billion for known cases of clinical negligence – with maternity services being one of the worst areas – but has no idea if the issue is getting better or worse.
Using a database of rulings, Byline Times identified some 616 PfD orders that were issued in the 2023-2024 financial year – up from 436 the year before. The figure was 437 in the 2021-2022 financial year and 338 the year earlier.
Campaigners told Byline Times that while PfD orders are important they lack teeth, as coroners lack the powers to ensure their recommendations are adhered to, and so, similar deaths don’t occur. Often recommendations are not implemented or ignored.
In two preventable death cases analysed by Byline Times, ambulance services arrived 13 hours late. One involved a caller with sepsis, the other was a plea for help from a person who had deliberately taken an overdose of medication. In a third case, ambulances arrived two hours late to a heart attack call. Coroners ruled the trio all died as a result of delays.
In another case, Madeline Savory committed suicide while waiting for an emergency mental health bed at a local hospital to become available, something a coroner said contributed to the teen’s death.