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Commentary

What can we learn from coroners’ reports on preventable deaths?

Jeraj S. What can we learn from coroners’ reports on preventable deaths? BMJ. 2024;386:q1943.

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October 23, 2024
Jeraj S. BMJ. 2024;386:q1943.
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Analysis of system failure is only the beginning of the improvement cycle. This article discusses an effort in the United Kingdom to learn from preventable deaths reported to coroners that occurred in variety of environments, including health care. The author suggests that the process has not realized its potential to reduce system weaknesses noted by state examiners due to a perceived lack of oversight and follow-through on recommendations.

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Jeraj S. What can we learn from coroners’ reports on preventable deaths? BMJ. 2024;386:q1943.