One person a week in England dies with undiagnosed, untreated tuberculosis (TB), according to a new study published in the journal Thorax. British-born, older men are among those most likely to have the disease discovered only after death, suggesting healthcare workers may be overlooking the possibility of TB in this demographic.
Postmortem Diagnosis as a 'Never Event'
Researchers argue that a postmortem diagnosis of TB should be considered a 'never event'—an incident that should never occur—prompting urgent investigations to prevent future deaths. Dr. Eleanor Morgan, co-author of the study and a resident doctor at Liverpool University Hospitals NHS Foundation Trust, stated: 'As TB rates continue to rise, we need to keep asking: “Could this be TB?”, even in people who do not fit the usual risk profiles.'
TB Rates at 10-Year High
Tuberculosis rates in England have reached a 10-year high, with 9.4 cases per 100,000 people in 2024. This figure is just below the World Health Organization's threshold for a 'low incidence country' of 10 cases per 100,000—a level expected to be exceeded when 2025 data is released. Most TB cases are diagnosed in people born outside the UK, with an average age of 36. However, the study found that those diagnosed postmortem tend to be older and British-born.
Key Risk Factors for Undiagnosed TB
The likelihood of postmortem diagnosis was higher in individuals living outside London and those with a history of drug or alcohol misuse. Children under four years old were also at increased risk, potentially due to underdeveloped immune systems, non-specific symptoms, and challenges in obtaining samples for testing. Dr. Tom Wingfield, senior author and researcher at the Liverpool School of Tropical Medicine, emphasized that TB deaths 'should trigger learning, not blame, so that services can identify where opportunities were missed and prevent the next avoidable death.'
Call for Routine Investigations
Wingfield noted that deaths related to superbugs like MRSA or clostridioides difficile are routinely investigated in the NHS. He suggested treating TB similarly—as a never event that triggers root cause analysis—to help prevent future fatalities. While the increase in TB rates is concerning, Wingfield said it should not cause panic, as 'TB is preventable, treatable and curable.'
Global Context and Pandemic Impact
Tuberculosis is the world's biggest infectious disease killer, with 1.23 million deaths and an estimated 10.7 million cases globally in 2024. The disease is preventable and treatable with special antibiotics, with recent advances reducing treatment duration even for drug-resistant forms. Disruptions to TB detection and treatment during the Covid-19 pandemic led to a resurgence, and experts fear that aid cuts by the US and other donors could have a similar impact.
Study Limitations
The researchers acknowledged limitations in the data, noting it was not possible to determine whether the individuals died from TB or with TB but from other causes. Dr. Paul Cleary, a consultant epidemiologist at the UK Health Security Agency and study co-author, stated that either scenario 'might represent missed opportunities to identify and treat the disease earlier, as well as to prevent possible transmission to others.'
