The role of the coroner has evolved from its early tax-gathering history, when it was a method of collecting revenue from suicides for the government and investigating the English habit of murdering their Norman invaders, to a modern role of investigating sudden, violent and unnatural deaths for the benefit of all of society. We thought improving drug safety might be one of those benefits.
The coroner system exists in some form across the world. Since medication errors are a worldwide problem, information from deaths suspected to be due to medication reported by coroners would be a potentially useful source of pharmacovigilance data. A colleague and I, and one of our first MPharm graduates from the University of Birmingham, decided to investigate the utility of UK coroner reports concerning medication errors.
We found their reports reflected some current and longstanding drug safety concerns, with opiates and anti-coagulants figuring in nearly half of coroners’ reports we looked at. The reports contain valuable and rich pharmacovigilance data, however some of the wider lessons from individual cases may be lost.
You can read the paper at Drug Safety here.
Post Image: In the Arms of Morpheus, Sir William Ernest Reynolds-Stephens, 1894.