Deaths in care homes in England and Wales: a national observational study of coroner reports, 2013-2025

Introduction

Around 400,000 people live in care homes in England and Wales. This population is expected to grow significantly in the next decade, due to a population living longer with complex multimorbidity. However, little is known about the extent of preventable harms or deaths in care homes, which was identified as a key research priority in the 2022 NHS Patient Safety Strategy. 

Methods

We undertook a national observational study of Prevention of Future Death (PFD) reports, issued by coroners in England and Wales. The Preventable Deaths Tracker (https://preventabledeathstracker.net/) was used to identify cases from inception (July 2013) until 2025, which were manually reviewed for inclusion, including care home residents aged ≥65 years whose death was related to their care. Demographics, coroners’ concerns, and responses from organisations were extracted. Descriptive statistics and content analysis were used to synthesise data.

Results 

We identified 284 cases (5% of all PFDs), with median age 85 years and majority female (55%). Most residents died in hospital (61%); 25% died in care homes. Place of death was not recorded in 11%.

Deaths were multifactorial. Falls contributed to over half (52%). A failure to identify clinical deterioration contributed to 130 deaths (46%), and poor or incomplete documentation contributed to 106 (37%) deaths. Coroners most frequently raised concerns regarding care provided by staff (85%) and poor documentation (48%).

Only 48% of PFD recipients responded. When they did respond, organisations frequently reported implementing new protocols (64%), improved training (50%), and initiating audits (47%).

Conclusions 

Deaths reported by coroners in care homes were dominated by falls and unrecognised clinical deterioration. Coroners’ concerns were overwhelmingly related to quality of care. Despite a statutory duty, fewer than half of recipients responded. Without a unified system for collating, disseminating, and auditing PFDs for both the health and social care systems, lessons will not be learnt.