Tracking preventable deaths in September 2024

A monthly update and review of coronial data

Welcome to Autumn and another monthly review from the Preventable Deaths Tracker. Last month, the Death Certification Reforms took effect in England and Wales with the official introduction of the Medical Examiner System on 9 September. The PDT is interested in seeing what data they share (if any) and will monitor how it impacts coronial data and mortality statistics.

Many highly anticipated reports were published last month, including Phase 2 of the Grenfell Tower Inquiry on 4 September and Lord Darzi’s Independent Investigation of the National Health Service in England on 12 September. The Lampard Inquiry into the deaths of mental health inpatients in Essex was also opened on 9 September.

It was World Patient Safety Day on 17 September, a global campaign to improve the safety of healthcare. However, how this is being done in the NHS is often untransparent and unsystematic, with cherry-picked data, reviews and alerts.

After more than 11 years of receiving coroners’ Prevention of Future Deaths reports (PFDs), NHS England finally published its “processes”, ironically on World Patient Safety Day. Although, it’s still unclear what action they’ve taken in the past 11 years to prevent future deaths.

Front cover news

I was interviewed for a story on preventable deaths, which made the front cover of the British Medical Journal! Data from the Preventable Deaths Tracker was featured, and several quotes from the interview: “The really important question that no one is asking [or funding] is what is the effectiveness of [PFDs] in saving lives?”

Four years of Tracking

September is a special month for the Preventable Deaths Tracker, as it marks four years since I published the website. Back then, it was just a two-dimensional site that hosted the web scraper, which I’d manually run and update whenever there was time. Now, that process is automated—but it won’t stop there.

The first version of the Preventable Deaths Tracker published in September 2020.

From a passion project that started during lockdown while writing my PhD to having over 130,000 users, I’m proud of what’s been achieved. Now, with the support of the King’s Prize Fellowship, a new version of the Preventable Deaths Tracker website is under construction. Stay tuned for its release in the coming months.

Onto the monthly review of coroner reports published in September…