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Number of Preventable Deaths in UK Doubles –but Coroner’s Orders to Stop Them Happening Again ‘Just Collect Dust’

More evidence that the UK health and emergency services have “profoundly failed” the NHS which is now in a “state of emergency”

A ward at the Royal Liverpool University Hospital, Liverpool. Photo: PA Images / Alamy
Preventable deaths were most common in medical settings, a Byline Times analysis of figures revealed. Photo: PA Images / Alamy

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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.

Coroners issue preventable death orders to try and stop tragedies from reoccurring – but authorities are not required to follow them. Photo: Russell Hart / Alamy

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”.

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“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.

Preventable deaths broken down by category since July 2013. Source: Preventable Deaths Tracker

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.

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The dangers outlined in the orders are compounded by the scale of backlogs at coroner’s courts – recent government data found thousands of families were now waiting over a year for a verdict.  So, not only are measures to prevent deaths increasing, and being ignored, but the system is failing to keep up with cases so changes and solutions are not being discovered in a timely manner.

Because authorities are not compelled to act on PfD orders, often tragedies continue to occur. One of the most extreme examples of this involved the Lakanal House Fire, which killed six people in Camberwell in 2009. 

Had recommendations outlined during an inquest into that tragedy been acted on lives could have been saved eight years later when Grenfell Tower caught fire. Seventy-two people died in what was the UK’s deadliest structural fire since 1988.

Government officials responded to the coroner’s proposals in the Lakanal case, including that housing providers should be “encouraged to consider” fitting sprinkler systems into high-rise blocks, by branding the inquest an “essentially pointless task” and saying the government “only have a duty to respond to the coroner, not kiss her backside”.

Aniesha Obuobie, a coordinator for the Grenfell Project and Coroner’s Court reform for the human rights group Inquest told Byline Times that “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.”

If we see that same thing being raised every time there’s an inquest into a similar death it’s very devastating for families to hear it’s happening again. Sometimes the same issue is being raised again over a death about the exact same place

Aniesha Obuobie, Grenfell Project and Inquest

Inquest is currently spearheading a campaign, dubbed ‘No More Deaths’, to try and give more powers to coroners and create a national oversight body that ensures everyone from the government to local councils and NHS Trusts act on concerns outlined during inquests.

The rising number of PfD orders has occurred in the backdrop of 14 years of government austerity that has devastated the public service, with the NHS, councils and local authorities struggling to fulfil their mandates amid continual funding cuts.

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A YouGov poll in October 2023, asked Britons about 12 key public services with the majority responding that most are in a bad state, with the NHS topping the list at 86%. Hospitals came next at 81%, social care and GPs, 78%, trains, 70%, police, 69%, prisons, 67%, schools, 63% and the courts and justice system, 57%.

The Ministry of Justice declined to comment on PfD orders and Byline Times’ findings.


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