A discursive analysis of coroners' construction of neglect in care home deaths

In England and Wales, coroners issue Reports to Prevent Future Deaths (PFDs) when an inquest identifies concerns that future deaths may occur unless action is taken. Although PFDs have increasingly been used to study preventable deaths in other contexts, care home deaths have remained largely unexamined. This study examined coroners' construction of neglect in care home deaths involving older adults and considered the implications for future prevention.

We undertook a Foucauldian Critical Discourse Analysis of 15 publicly available PFDs published on the Courts and Tribunals Judiciary website between 2018 and 2022. The reports concerned deaths of adults aged 60 years and over in which neglect formed part of the inquest conclusion.

Coroners constructed neglect in two principal ways. "Dark room" neglect referred to immediate danger associated with residents being left unobserved or exposed to acute hazards. "Forgotten space" neglect referred to cumulative omissions, missed opportunities, and prolonged deterioration. Both constructs were aligned with a discourse of risk prevention that privileged institutional oversight, assessment, and management.

The findings reveal tensions between dominant and alternative discourses regarding risk and neglect in care homes. PFDs made some risks highly visible while rendering others less visible, particularly the relational and organizational conditions in which neglect develops. Greater attention to family knowledge, frontline staff experience, and cumulative deterioration may support collaborative approaches to prevention in care homes.