The aim of this study was to establish if in patients who die at scene as a result of a traumatic cardiac arrest (TCA), their cause of death could be determined through coroners reports, and to ascertain the quality of the feedback provided.

This is a retrospective study of all patients presenting in TCA who were attended by the Kent, Surrey and Sussex Air Ambulance trust between 1 January 2015 and 30 June 2016.

In total, 159 patients were attended during the study period. PM reports could not be obtained for 37 patients, mainly due to unestablished identities at scene. Forty of the 122 reports obtained were full PM reports, 3 were inquest reports and for 79 patients only their (presumed) cause of death was provided. A specific cause of death was provided for 68 patients, whereas in the remaining 54 patients the cause of death was given as “multiple injuries”. In 32% of the patients with a full PM report, injuries were identified during the post mortem examination that had not been noted on scene.

Feedback from coroners to pre-hospital teams after patients die as a result of a TCA is important, but currently suboptimal.