Quality improvement themes from coronial recommendations received by the Chief Psychiatrist
Under the provisions of the Mental Health Act 1986, mental health services are required to notify the Chief Psychiatrist of the death of any patient that is a reportable death within the meaning of the Coroner’s Act 1985. The Chief Psychiatrist registers an interest with the coroner regarding the findings arising from any coronial inquest or inquiry into these deaths. The Chief Psychiatrist is in a unique position to review these findings and to identify emerging themes across the service system.
Currently, the Chief Psychiatrist publishes regular summaries of coronial findings for the mental health sector – these summaries draw together the key clinical practice and standards issues for a given period and highlight areas for ongoing quality improvement action. Services are encouraged to review their local practices, policies and procedures and implement action plans to address the issues identified.