Abstract
Introduction
Falls in older people are common and can lead to significant harm including death. Coroners in England and Wales have a duty to report cases where action should be taken by organisations to prevent deaths, but dissemination of the findings from these Prevent Future Deaths (PFD) reports remains poor, limiting their possibility to effect change. We set out to identify preventable fall-related deaths, classify coroners’ concerns, and explore organisational responses to these deaths.
Methods
A protocol for a retrospective case series of fall-related PFDs was pre-registered. A novel, openly available, computer code was created to download and read PFDs from the Courts and Tribunals Judiciary website from July 2013 to November 2022. Demographic information, coroners’ concerns and responses from organisations were extracted. Descriptive statistics and content analysis were used to synthesise data.
Results
527 PFD cases (12.5% of all PFDs) involved a fall that contributed to death. These deaths predominantly affected older people (median 82 years) in the community (72%), with subsequent death in hospital (71%). A high proportion of cases experienced fractures, major bleeding, or head injury. Coroners frequently raised concerns regarding falls risks assessments, failures in communication, and documentation issues. Only 56.7% of PFDs received a response from the intended recipients. Organisations most commonly produced new protocols, improved training, and commenced audits in response to PFDs.
Conclusion(s)
One in eight preventable deaths reported in England and Wales involved a fall. Adequately addressing concerns raised by coroners should improve falls prevention and care following falls especially for older adults. Poor responses to coroners may indicate that actions are not being taken at the local level. Wider dissemination and learning from PFD findings may help reduce preventable fall-related deaths nationally.