REPORTING OF DEATHS TO THE CORONERS OFFICE

1
REPORTING OF DEATHS TO THE CORONERS OFFICE

• Dr Ian Carson
• Executive Medical Director
• The Northern Hospital

2
Adverse Events Deaths in Hospitals

• Department of Human Services Victoria introduced
  Sentinel Events Program in July 2001. List
  revised June 2002.
• This provides a list of 8 proscribed events that
  require mandatory reporting to DHS.
• Each case then requires follow up and Root Cause
  Analysis including remedial actions.
• This analysis must be reported back to DHS
  including changes made follow up plans.

3
Current List of Sentinel Eventsas revised 28
June 2002

• Procedures involving wrong patient/body part
• Suicide in hospital
• Retained instruments/other material after surgery
  needing further surgical intervention
• Intravascular gas embolism resulting in death or
  neurological damage
• Haemolytic blood transfusion from ABO
  incompatibility

4
Sentinel Events (contd)

• Medication error leading to the death of a
  patient reasonably believed to be due to
  incorrect administration of drugs
• Maternal death or serious morbidity associated
  with labour or delivery
• Infant discharged to wrong family
• 8 Sentinel Events in all with 4 also being
  reportable to the Coroner

5
Compliance with the program?

• Seems to be good
• DHS can monitor failed reporting from Discharge
  Codes as can hospitals themselves
• Problem 1 some serious cases dont fall into
  this system and could be missed or ignored
• Problem 2 Root Cause Analysis skills are still
  generally poor at hospital level
• Problem 3 Resource issues for both DHS and
  hospital staff re time and coordination of staff
• Problem 4 Colleges dont seem to be involved
• Problem 5 Clinician suspicion of Big Brother
  watching them

6
Reporting Deaths to the Coroner

• Legislation Coroners Act 1985
• Victorian Parliament Law Reform Committee has
  issued a Discussion Paper submissions are due
  by 15 July 2005
• The 1985 Act requires that Doctors who are
  present at or after certain kinds of deaths
  must report that death to a Coroner

7
Deaths requiring coronial notification

• The death is reportable
• The doctor does not view the body
• The doctor is unable to determine the cause of
  death
• No doctor attended the deceased within 14 days
  before death the doctor is unable to determine
  the cause from the deceaseds immediate medical
  history
• The death is reviewable

8
Reportable deaths

• Defined in the Act s.3(1)
• Two requirements
• the death must in some way be connected with
  Victoria
• The death must meet one of the criteria set out
  in the Act including,
• Unexpected, unnatural, violent, accidental death
• Deaths involving anaesthetics
• Deaths of persons in custody or in care
• Deaths where identity or cause not established

9
Reviewable deaths

• Introduced as an amendment to the 1985 Act in
  2004
• As a result of concerns regarding situations
  where more than one child in a family dies
• - body must be in Victoria
• death must have occurred in Victoria
• the cause of death occurred in Victoria
• the child must normally reside in Victoria
• being the death of a second or subsequent child
  of a parent

10
Compliance with coronial reporting

• Variable from doctor to doctor
• Understanding of the coroners role varies
• Experience of dealing with reporting varies from
  doctor to doctor and even case to case
• Coroners Handbook for families is useful
• Undergraduate teaching seems to be lost in the
  myriad of clinical/admin new tasks
• Loss of a Pathology Dept on site in many cases
  compounds the poor understanding

11
Compliance with reporting

• 24 hours a day nature of the problem works
  against a consistent approach by all doctors,
  coroners clerks, police attending.
• Often the most junior staff certifying death so a
  constant need to educate. Rotations.
• Due to rotations and time delays in the whole
  process no feed back to referrer
• Seniors understand the issue only if they have
  been through the process themselves

12
Compliance with reporting

• Act is unclear of what is an unexpected death -
  and unexpected to whom?
• Act is also unclear as to what constitutes an
  unnatural death eg asbestos and lung disease
  yes?, tobacco and lung disease no?, alcohol and
  cirrhosis of liver no? Legal v Medical view.
• VIFM has published guidelines on MPBV website but
  at 2am would an RMO know? Or have time?
• Do we need a special category of reportable
  deaths related to medical treatment?
• Still confusion of how long after an incident
  do you need to report, eg a late anaesthetic
  death
• In Custody or In Care not always recognised

13
Possible aids to improve reporting

• Better definitions in the Act
• A Coroners Court Handbook for clinicians
• A wider educational role with hospitals and
  clinicians for the Clinical Liaison Service
• Increased understanding for all clinicians of
  what is actually happening at the Coroners Court
  The Communique, wider and more consistent
  distribution of Inquest Findings to clinicians
  and hospitals, particularly the sharing of
  improvements developed in other facilities
• Convince clinicians it will help patients, not
  courts