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

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.