{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T23:36:55Z","timestamp":1787960215215,"version":"build-2784847793"},"reference-count":40,"publisher":"Oxford University Press (OUP)","issue":"4","license":[{"start":{"date-parts":[[2023,8,22]],"date-time":"2023-08-22T00:00:00Z","timestamp":1692662400000},"content-version":"vor","delay-in-days":1,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000272","name":"National Institute for Health Research","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"publisher"}]},{"name":"Preventable Deaths Tracker"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2023,11,29]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Opioid deaths have increased in England and Wales. Coroners\u2019 Prevention of Future Deaths reports (PFDs) provide important insights that may enable safer use and avert harms, yet reports implicating opioids have not been synthesized. We aimed to identify opioid-related PFDs and explore coroners\u2019 concerns to prevent future deaths.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>In this systematic case series, we screened 3897 coronial PFDs dated between 01 July 2013 and 23 February 2022, obtained by web scraping the UK\u2019s Courts and Tribunals Judiciary website. PFDs were included when an opioid was implicated in the death. Included PFDs were descriptively analysed, and content analysis was used to assess concerns reported by coroners.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Opioids were involved in 219 deaths reported in PFDs (5\u00b76% of PFDs), equating to 4418\u00a0years of life lost (median 33\u00a0years\/person). Morphine (29%), methadone (23%) and diamorphine (16%) were the most common implicated opioids. Coroners most frequently raised concerns regarding systems and protocols (52%) or safety issues (15%). These concerns were most often addressed to National Health Service (NHS) organizations (51%), but response rates were low overall (47%).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Opioids could be used more safely if coroners\u2019 concerns in PFDs were addressed by national organizations such as NHS bodies, government agencies and policymakers, as well as individual prescribing clinicians.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/pubmed\/fdad147","type":"journal-article","created":{"date-parts":[[2023,8,22]],"date-time":"2023-08-22T02:24:52Z","timestamp":1692671092000},"page":"e656-e663","source":"Crossref","is-referenced-by-count":10,"title":["Preventable deaths involving opioids in England and Wales, 2013\u20132022: a systematic case series of coroners\u2019 reports"],"prefix":"10.1093","volume":"45","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5344-1967","authenticated-orcid":false,"given":"Francesco","family":"Dernie","sequence":"first","affiliation":[{"name":"Oxford University Hospitals NHS Trust , Oxford OX3 9DU , UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Harrison S","family":"France","sequence":"additional","affiliation":[{"name":"Oxford Medical School , Medical Sciences Divisional Office, , Oxford OX3 9DU , UK"},{"name":"University of Oxford , Medical Sciences Divisional Office, , Oxford OX3 9DU , UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth T","family":"Thomas","sequence":"additional","affiliation":[{"name":"Centre for Evidence-Based Medicine , Nuffield Department of Primary Care Health Sciences, , Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG , UK"},{"name":"University of Oxford , Nuffield Department of Primary Care Health Sciences, , Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG , UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maja","family":"Bilip","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Thames Hospital , MacKay Street, Thames 3500 , New Zealand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicholas J","family":"DeVito","sequence":"additional","affiliation":[{"name":"Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford , Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG , UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robin E","family":"Ferner","sequence":"additional","affiliation":[{"name":"Institute of Clinical Sciences, University of Birmingham , Birmingham , UK"},{"name":"West Midlands Centre for Adverse Drug Reactions, City Hospital , Birmingham B17 7QH , UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2294-3440","authenticated-orcid":false,"given":"Anthony R","family":"Cox","sequence":"additional","affiliation":[{"name":"Institute of Clinical Sciences, University of Birmingham , Birmingham , UK"},{"name":"West Midlands Centre for Adverse Drug Reactions, City Hospital , Birmingham B17 7QH , UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carl","family":"Heneghan","sequence":"additional","affiliation":[{"name":"Centre for Evidence-Based Medicine , Nuffield Department of Primary Care Health Sciences, , Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG , UK"},{"name":"University of Oxford , Nuffield Department of Primary Care Health Sciences, , Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG , UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeffrey K","family":"Aronson","sequence":"additional","affiliation":[{"name":"Centre for Evidence-Based Medicine , Nuffield Department of Primary Care Health Sciences, , Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG , UK"},{"name":"University of Oxford , Nuffield Department of Primary Care Health Sciences, , Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG , UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0244-5620","authenticated-orcid":false,"given":"Georgia C","family":"Richards","sequence":"additional","affiliation":[{"name":"Centre for Evidence-Based Medicine , Nuffield Department of Primary Care Health Sciences, , Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG , UK"},{"name":"University of Oxford , Nuffield Department of Primary Care Health Sciences, , Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG , 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