Deaths involving tuberculosis reported by coroners in England and Wales: a national case series and policy review

Abstract Background Tuberculosis (TB) is the leading cause of death from a single infectious agent worldwide. Although the United Kingdom (UK) is a low-incidence country, it has not met global targets to reduce TB deaths in line with the World Health Organisation (WHO) End TB strategy. This study aimed to determine how many deaths from TB were reported to organisations by coroners in England and Wales to identify lessons from these reports and create a live surveillance tool to measure progress. Methods The Preventable Deaths Tracker, a national database of all coroners’ Prevention of Future Deaths reports (PFDs), was used. Keywords were used to search 5,036 PFDs and identify deaths involving TB. Descriptive statistics were used to synthesise the data, and thematic analysis to assess concerns reported by coroners and organisational responses to coroners. Finally, we reviewed pertinent UK guidelines and policies to assess whether coroners’ concerns were addressed, and developed a live surveillance tool. Results Five deaths involving TB were reported by coroners between July 2013 and 19th May 2024, with a median age at death of 28 years, equivalent to 234 years of life lost. 21 concerns were raised by coroners, grouped into five themes, including TB posing an occupational risk, and insufficient guidelines and protocols for prevention and treatment. UK policy implementation addresses coroners’ concerns on out-of-hours access to general practitioner records, and UK guidelines highlight biological immunosuppressive treatment as a risk for TB. Significant ambiguity around occupational risks of TB for health workers remained, including guidance for latent TB screening and contact tracing for TB-exposed health workers. A surveillance tool was created to monitor the ongoing publication of PFDs involving TB. Conclusions Using thematic analyses and a guideline review, we identified learnings from PFDs, finding that some had not been addressed in the guidelines, including latent TB screening protocols and healthcare workers as an at-risk group for TB in England and Wales. PFDs provide valuable insights for preventing future deaths involving TB, and can help catalyse and monitor action taken in low-TB-burden, high-income countries to achieve the goals set in the WHO End TB plan.