A network and thematic analysis of mental health-related Prevention of Future Death reports from 2013 to 2025 in England and Wales

Br J Psychiatry. 2026 Feb 5:1-9. doi: 10.1192/bjp.2025.10528. Online ahead of print.

ABSTRACT

BACKGROUND: Coroners’ Prevention of Future Death reports (PFDRs, also known as Regulation 28 reports) provide an opportunity to understand factors contributing to mental health-related deaths.

AIMS: To examine available mental health-related PFDRs, addressing three core questions: (a) What is the overall profile of these reports? (b) What relational patterns emerge from these reports? and (c) What concerns and preventive actions do coroners highlight in these reports, and how they evolved over time?

METHOD: We collected all mental-health related public PFDRs available up to June 2025 (N = 586). Data extraction combined automated web scraping, optical character reading and large language model (LLM)-assisted (GPT-4o) parsing to capture demographics, settings, coroner areas, co-occurring categories, concerns and recommended actions. Descriptive statistics, category and recipient co-occurrence network analysis and thematic analysis were used to provide a comprehensive landscape of these reports.

RESULTS: Report numbers increased steadily from 2013, peaking in 2021 and then declined. Some jurisdictions, including Manchester South, East Sussex and East London, consistently had more PFDRs issued. The deceased were typically young, male and had died mainly outwith hospital, most often at home; 78.0% of reports included at least one formal response from recipients, whereas 22.0% had no corresponding response available. The network analyses suggested that PFDRs seldom identified isolated issues. Coroners’ concerns changed over time, from service access and resources to inter-agency coordination and then, more recently, to risk assessment and management.

CONCLUSIONS: Mental health-related deaths examined by coroners arise within complex, evolving multi-sector contexts and do not frequently identify single errors. Minimising such deaths may require coordinated strategies across healthcare, social care and justice systems. Analysis of PFDRs allows identification of patterns that may inform such actions. PFDRs should be analysed routinely and patterns followed over time.

PMID:41640055 | DOI:10.1192/bjp.2025.10528