Preventable deaths involving falls in England and Wales, 2013–22: a systematic case series of coroners’ reports

Abstract Background Falls in older people are common, leading to significant harm including death. Coroners have a duty to report cases where action should be taken to prevent future deaths, but dissemination of their findings remains poor. Objective To identify preventable fall-related deaths, classify coroner concerns and explore organisational responses. Design A retrospective systematic case series of coroners’ Prevention of Future Deaths (PFD) reports, from July 2013 (inception) to November 2022. Setting England and Wales. Methods Reproducible data collection methods were used to web-scrape and read PFD reports. Demographic information, coroner concerns and responses from organisations were extracted and descriptive statistics used to synthesise data. Results Five hundred and twenty-seven PFDs (12.5% of PFDs) involved a fall that contributed to death. These deaths predominantly affected older people (median 82 years) in the community (72%), with subsequent death in hospital (70.8%). A high proportion of cases experienced fractures (51.6%), major bleeding (35.9%) or head injury (38.7%). Coroners frequently raised concerns regarding falls risks assessments (20.9%), failures in communication (20.3%) and documentation issues (17.5%). Only 56.7% of PFDs received a response from organisations to whom they were addressed. Organisations tended to produce new protocols (58.5%), improve training (44.6%) and commence audits (34.3%) in response to PFDs. Conclusions One in eight preventable deaths in England and Wales involved a fall. Addressing concerns raised by coroners should improve falls prevention and care following falls especially for older adults, but the poor response rate may indicate that lessons are not being learned. Wider dissemination of PFD findings may help reduce preventable fall-related deaths in the future.