Information From Coroners’ Inquests

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Chapter: Pharmacovigilance: Fatal Medication Errors and Adverse Drug Reactions - Coroners’ Inquests and Other Sources

Coroners in England and Wales have to determine how a person dies if death is from a violent, unnatural or unknown cause.


Coroners in England and Wales have to determine how a person dies if death is from a violent, unnatural or unknown cause. Deaths due to errors in prescrib-ing, dispensing or giving drugs, and those caused by ADRs, fall within these categories. Coroners have extensive powers of investigation.

There are some caveats. The facts are not always clear, and so some deaths may be regarded as natural that in fact are because of therapy. Even if the facts are clear, the decision to report a death to the Coroner is not always straightforward, so some deaths may be reported by one doctor but not another. The extent of underreport-ing is unknown. Each Coroner’s Court covers deaths occurring in a defined area, so that, broadly speak-ing, the size of the population served by the Court is known. Local circumstances, such as the presence of a regional referral centre for some condition that is often fatal (such as liver failure), can however inflate the apparent incidence of deaths due to that cause.

We have previously described the findings in cases of death due to ADRs or to medication errors in one Coroner’s district, Birmingham and Solihull, between  1986 and 1991 (Ferner and Whittington, 1994). We then extended those data to cover the period January 1986 to June 2000 (Ferner and Whittington, 2002). Here, we present further data from the Birmingham and Solihull Coroner’s Court for the period November 2001–June 2005.

There were significant differences in the collec-tion and analysis of the data, most notably because Dr Richard Whittington, who was medically qual-ified, retired before the start of this third period, and Mr Aidan Cotter, a solicitor, became Coroner. Moreover, some of the processes have changed, as explained below. There also exists the possibility that the two Coroners might differ in their verdicts on the same set of facts, so that one might categorise a case as because of an adverse drug event, whereas the other would not. We have not been able to investigate this aspect of Coronial decision-making.

The population in 1991 was 1.21 million people, and the number of deaths was approximately 13 000 per year, of which approximately 4% were reported to the Coroner. In 2004, the population was 1.32 million, with approximately 11 000 deaths per year.

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