Key result
Anticoagulant-related CV deaths frequently involve systems failures, yet ~60% of coroner warnings receive no response.
Why the study?
Anticoagulants remain important for managing cardiovascular disease, but coroners' reports provide insights into preventable deaths involving these agents that require synthesis.
Observational (n=113)
Coroners' reports highlight systemic failures, poor communication, and inadequate record-keeping as key contributors to preventable deaths involving anticoagulants in cardiovascular disease, yet the majority of these reports receive no formal response.
PFDs reveal recurring safety lapses with anticoagulants in CVD; leaves open whether addressing them reduces preventable deaths.
BACKGROUND: The global burden of cardiovascular disease (CVD) is forecast to increase, and anticoagulants will remain important medicines for its management. Coroners' Prevention of Future Death reports (PFDs) provide valuable insights that may enable safer and more effective use of these agents. AIM: To identify CVD-related PFDs involving anticoagulants. DESIGN & SETTING: Case series of coronial reports in England and Wales between 2013 and 2019. METHOD: A total of 3037 PFDs were screened for eligibility. PFDs were included where CVD and an anticoagulant caused or contributed to the death. Included cases were descriptively analysed and content analysis was used to assess concerns raised by coroners and who had responded to them. RESULTS: = 12) were the most common anticoagulants reported. Concerns most frequently raised by coroners included poor systems (31%), poor communication (25%), and failures to keep accurate medical records (25%). These concerns were most often directed to NHS trusts (29%), hospitals (10%), and general practices (8%). Nearly two-thirds (60%) of PFDs had not received responses from such organisations, which are mandatory under regulation 28 of the Coroners' (Investigations) Regulations 2013. A publicly available tool has been created by the authors (https://preventabledeathstracker.net), which displays coroners' reports in England and Wales to streamline access, and identify important lessons to prevent future deaths. CONCLUSION: National organisations, healthcare professionals, and prescribers should take actions to address the concerns of coroners in PFDs to improve the safe use of anticoagulants in patients with CVD.
No takes yet. Share an insight, caveat, or question.
Anis et al. (2021) conducted an observational in Cardiovascular disease involving anticoagulants (n=113). Anticoagulants was evaluated on Concerns raised by coroners and response rates from addressed organizations. In 113 cardiovascular disease-related deaths involving anticoagulants, coroners frequently raised concerns about poor systems (31%) and communication (25%), yet 60% of reports received no response.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: