In June, I received feedback from a user of the Preventable Deaths Tracker (PDT). They had spoken with a clinical colleague who said they thought the PDT “didn’t do/show anything” that the Judiciary website offered.
The user, who is actively using the PDT for a project on child deaths, suggested I make it clearer what the Tracker provides compared to the Judiciary website. So now on the new landing page, you’ll find a list of the PDT’s current features.
The two primary tools described here are the PDT’s relational database and the searchable repository, which are very different to the tools on the Judiciary website.
Tools on the Judiciary website
On the Judiciary website, the ‘keyword’ search will only work for reports published since 1 January 2023, and only if the report was machine-readable to begin with. This is possible because the Chief Coroner’s Office started to copy and paste the content of reports directly onto the Judiciary website after I had several round-table discussions with the Office about the need to digitalise reports.
In comparison, the Preventable Deaths Tracker has a live, searchable repository of all published reports and responses since 2013, with almost 13,000 digitalised files in the repository, it is an extremely powerful resource that has the potential to save lives.
Next on the Judiciary website is the ‘PFD Report type’ filter that lists 17 categories. I’ve previously written about the issues with these categories, including our research on suicide, which found that only 20% of suicides were assigned to the suicide category on the Judiciary website. One concerning category here is ‘Other related deaths’ - with 740 reports without any categorisation, limiting learning.
Due to concerns over the accuracy, duplication, and obsolescence of categories, the Preventable Deaths Tracker does not use the Chief Coroner’s Office ‘PFD Report type’ categories. Instead, I’ve co-created a new list of 24 categories to encompass all types of deaths reported by coroners in PFDs, including new categories for the 740 ‘Other related deaths’. Now the hard work has begun to review and recategorise all PFDs, so stay tuned for more on this.
The third and final tool on the Judiciary website is the ability to sort and filter reports by their date of publication, not the date of report. To provide accurate analytics and statistics, the Preventable Deaths Tracker uses the date of report.
In summary, the Judiciary website hosts and publishes coroners’ Prevention of Future Deaths reports (PFDs), but the tools for accessing and using these reports remain limited. Following the first Parliamentary inquiry into the Coroner Service (2020-21), the Chief Coroner’s Office revamped the website in August 2022, allowing keyword searches, filtering by ‘PFD Report type’, and sorting by date of publication. In January 2023, the text of reports began to be published online, but this remains patchy.
Real-time, live statistics
By converting descriptive information into structured data, the Preventable Deaths Tracker (PDT) provides useful statistics, which update in real time. Because of the PDT’s longitudinal data, benchmarking, audits, and progress can be measured.
The Preventable Deaths Tracker was the first to openly report on the number of PFDs written by coroners each year - i.e. the importance of using the date of report, not the date of publication. From the PDT, we now know that very few PFDs are written annually, an average of ~450 per year. However, based on 2025 statistics thus far, more than the average will be written again this year.
Real people, not just reports
This summer, the Preventable Deaths Tracker (PDT) expanded its tools to include a real-time count for the number of deaths reported in PFDs. This is an important milestone, made possible by the new relational database I launched earlier this year.
By ignoring the people behind the data, statistics are underestimated. Our value of loss calculation now uses the number of deaths to calculate the Value of a Prevented Fatality (VPF), bringing it to a total of £16 billion. Yes, billion.
Tools for tracking responses
The Preventable Deaths Tracker (PDT) is the only platform that provides open statistics on responses to coroners’ reports, which automatically update in real-time.
Over the summer, I worked with the Chief Coroner’s Office (CCO) to audit their “non-responses” list using the PDT’s tools. Almost 100 discrepancies were identified, which led to over 30 missing responses being published by the CCO and PFDs missed by the CCO being added to their list, demonstrating how the PDT can support their work.
These collective efforts now mean that PFDs written in 2024 have the highest response rates ever seen. Almost 93% of PFDs in 2024 have all responses published, demonstrating the power of data, rather than the need for another National Oversight Mechanism.
Organisations that receive reports
The Preventable Deaths Tracker (PDT) is the only platform that provides open statistics on who receives coroners’ reports and if they respond. Since 2013, over 2,200 organisations have received reports, with most sent to the Department of Health and Social Care (DHSC) and NHS England.
I often receive emails from organisations that have used the PDT to audit their responses to PFDs, leading to missing responses being published.
Filtering preventable deaths
The Preventable Deaths Tracker (PDT) is the only platform that allows PFDs to be filtered by date of report, addressees, coroners and regions. By clicking areas on the map, statistics automatically update, and reports can be downloaded. Creating a secure account allows the data to be stored and filters reused to systematically track changes over time.
Using the PDT, all reports for Wales can be easily identified by selecting the seven coroner areas for Wales, demonstrating why the Judiciary’s “Wales prevention of future deaths reports (2019 onwards)” category is obsolete and incomplete.
Despite the enormous economic cost (£16 billion and growing), the government has no plans to take action to prevent similar deaths. Until then, the Preventable Deaths Tracker will keep tracking.