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Amanda Charles

Amanda Charles

Risk Manager at Austin Health, Heidelberg, Victoria Australia

Title: Reporting deaths to the coroner-what do nurses understand about the process?

Biography

Biography: Amanda Charles

Abstract

Statement of the Problem:

The value of death investigation within the health sector can be an extremely valuable tool in the provision of safe patient care. Some deaths which occur in hospital are required to be reported to the coroner’s office. These deaths undergo a review process, with the findings and /or recommendations  returned to the hospital as lessons learned. This process assists in identification of factors that may have prevented the death, again enhancing ongoing care.

Methodology & Theoretical Orientation: Twenty two semi structured interviews were recorded and transcribed which includes nursing staff (N=10). The interview questions were designed to determine the clinician’s understanding of deaths that are reportable to the coroner and why this reporting is required. This study was performed in a tertiary referral hospital in Melbourne, Australia, and the health service offers a variety of acute and subacute services, across several sites.

Conclusion & Significance: :  There were consistent themes identified during the analysis included a lack of awareness of which deaths meet the reportable criteria, and why those deaths are required to be reported, together with educational support and feedback .

Although the reporting of deaths to the coroner is primarily the role of the medical staff in Victoria, Australia  the ability of nursing staff to be influential and informed in this area should not be underestimated. The pursuit of a safer environment for our patients within our hospital can be enhanced by the lessons from coronial investigation. For this to review to occur, these deaths must be reported