Medicines and other factors causing deaths in English and welsh care homes: five-years of preventing future death reports by coroners

Background Whilst information has been published on the impact, severity and causes of incidents involving medicines in care homes, it has not been systematically described. This review explored whether coroners’ Preventing Future Death (PFD) reports involving medicines for people living in care homes could add to this evidence base. Methods PFD reports made publicly available between 2017 and 2021 classified as ‘care home-related deaths’ were reviewed. Reports describing medicines and/or medicines processes were identified. Contributory factors within these reports were then identified. Results Within the timeframe, 156 reports were published, and 25 described medicines (n = 27) or medicines processes (n = 5) concerning people living in care homes. The impact of medicines and/or medicines processes was quantified as no impact (n = 7), contributory (n = 6) and direct (n = 14) per report. Two key themes emerged. Four deaths had an association between their falls risk, prescribed anticoagulants, and the failure of the service to seek timely emergency care following a fall and two deaths concerned endocrine medicines, where people refused insulin or blood sugar monitoring and staff did not seek timely advice. Conclusion This study demonstrated PFD reports provide an insight into the potential association between medicines, and other aspects of the person’s care in causing harm.