Tracking preventable deaths in March and April 2025

Two for one

Welcome to the Preventable Deaths Tracker's combined review for March and April, marking my Substack newsletter anniversary. It’s now been two years since my first post on 19 March 2023. In the last two years, I’ve published 67 posts, resulting in over 69,000 views from 32,000 users and over 2,200 subscribers—a huge thank you for all your support, feedback and interest in my work.

Last month, I spent a week in Oxford teaching and coordinating a module on the MSc in Evidence-Based Health Care, called Knowledge Into Action. Teaching is often seen as a burden to one’s research career, but I find it the most rewarding, learning something new every time I teach. I delivered a lecture for Sir Peter Thornton’s Death Investigation course at King’s College London, and to the Independent Advisory Panel on Deaths in Custody (IAPDC) and the All-Party Parliamentary Group (APPG) on Eating Disorders.

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On 26 March, the UK government presented its Spring Statement, announcing plans to cut 10,000 civil service jobs. This news followed the earlier announcement on 13 March that the “biggest quango in the world”, NHS England, would be closed and functions brought within the Department of Health and Social Care. On 7 April, the Cabinet Office announced that all quangos will be reviewed for potential closure or merger. So why is this important for the Preventable Deaths Tracker?

Many quangos across government receive reports from coroners to take action to prevent future deaths. However, it’s been almost impossible to understand how many they’ve received, whether they’ve responded, and how this information is used within and across government to prevent future deaths. The Preventable Deaths Tracker is filling this gap.

A very important quango, the Medicines and Healthcare products Regulatory Agency (MHRA), launched a new “Safety Roundup” on 25 March to improve its communications regarding the safety of medicines and medical devices. Their first alert was published on 29 April, and the sign-up for alerts is here.

The coronial workforce

I missed some news from February that I wanted to share, as it provides important insights into the challenges and workforce of coroners. On 24 February, the Judicial Attitude Survey 2024 was published. This survey is important as it’s the first time coroners have been included collectively as part of the judiciary rather than separately, as in 2023 and 2020. While coroners reported the highest levels of job satisfaction, personal safety, security, workload, financial constraints, and stress were notably high.

Two statistics I wanted to highlight:

• Coroners’ previous legal work (Table 17.8): Most were solicitors before becoming coroners, with 4-6% reporting ‘Other non-legal work’. This is of interest as the qualifications of coroners have significantly shifted from being primarily medical to predominantly legal, which was solidified by the Coroners and Justice Act 2009 that came into force in 2013. Whether and how this has impacted practice, particularly for the more complicated medical deaths, has not been explored.

• First appointed to post (Table 17.13): Most (53%) Senior Coroners were appointed more than 15 years ago, with three appointed in 1970. Unlike other jurisdictions, Senior Coroners in England and Wales can remain in their roles until the mandatory retirement age of 75 and are not subject to regular reelection. The removal or dismissal of coroners in England and Wales is rare and only for incapacity or misbehaviour. This high threshold means that coroners operate with a significant degree of independence.

Martyn’s Law

On 3 April 2025, the Terrorism (Protection of Premises) Act 2025, also known as Martyn’s Law, received Royal assent. This statute was introduced in response to the Manchester Arena bombing in 2017, which killed 22 people, including Martyn Hett, whose mother, Figen Murray, campaigned for this new law. It requires venues hosting events with more than 200 participants to make plans and train staff to respond to any potential terrorist attack. While this legislation is welcomed, it is yet another example of the broken system that relies on the goodwill of dedicated individuals and campaigns by grieving families for any action to be taken.

I know many of you receiving this email are active campaigners, so I’m delighted to share and encourage you to apply or nominate someone for a Tenacious Award—this is an initiative of the charity Changing Ideas and applications close on 15 May 2025.

Changing Ideas

Changing Ideas has recently awarded the Preventable Deaths Tracker a grant to expand the database to Scotland and hire its first staff! I am thrilled to share this next phase of work, and I sincerely thank David Graham and his team for their support and belief in my vision.

Support like this will accelerate the mission of the Preventable Deaths Tracker—to save lives by enabling learning from avoidable and premature deaths. The Tracker provides the tools to conduct life-saving research and advocacy. If you can support us, please get in touch and subscribe.

For those who are lucky enough to have never experienced an inquest or are just starting to learn about the death investigation system in England and Wales, this article, published in The Conversation on 11 March by the Voicing Loss research team, is a must-read.

“Over the course of our research, we heard from bereaved people who told us that their deceased relative had been denied justice; that there was no accountability for the death; and that they saw little prospect of change that would help to prevent similar deaths in the future.” ~Voicing Loss, 2025.

Very little (if any!) research funding is available to investigate and improve the Coroner Service, hence the importance of the Voicing Loss project. The judicial system is slow and lacks the skills and resources to generate research and evidence-based policy for death prevention. As a result, things stay the same.

Natasha Allergy Research Foundation

While I’m very excited to share more good news about funding support, it is another example of how families and charities take on the burden of improving the system. The Preventable Deaths Tracker has received a research grant from the Natasha Allergy Research Foundation (NARF) to finish a study on anaphylaxis-related deaths. I was first introduced to the NARF by Andy Slaughter MP back in 2023. Andy and the NARF have been important supporters of my work, so I’m delighted to formally work together with the NARF on this project. A huge thank you to Nadim and Tanya Ednan-Laperouse OBE, Trustees and Baroness Alicia Kennedy for commissioning this vital research.

You can listen to my interview with Tanya Ednan-Laperouse OBE, the Co-Founder and Trustee of NARF and the mother of Natasha, here.

Allergies: Beware, Be Ready

Now, let's move on to the dual monthly statistics for March and April 2025.