Standards
Standardising the coronial process allows investigations to be specifically
directed to identify and rectify system failures in healthcare. Standardised
investigations will generate more reliable and valid information
from the State Coroner's Office.
Coroner's "Investigation Standard": Fall-related deaths
in hospital
In May 2003, the Clinical Liaison Service (CLS) convened and facilitated
a forum to review the role of the Coronial process in the investigation
of fall-related deaths in hospital.
The Falls Forum and subsequently, the Falls Working
Party involved a multidisciplinary team comprising:
- Coroners (Victorian State Coroner's Office)
- State Coroner's Assistants (Victorian State Coroner's Office)
- Clinical Liaison Service (Victorian State Coroner's Office)
- Researchers (National Ageing Research Institute)
- Policymakers (Department of Human Services - Aged Care)
- Health service providers (
Bayside Falls Prevention Project
)
- Victorian Quality Council
- Consumers (Health Service Commissioner)
The objectives of this collaboration were three-fold as described
below:
- The Falls Forum was convened to provide Coroner's
Office staff with a general overview of the current research
initiatives, practice changes and administrative systems that
are used for the prevention and management of patient falls in
hospital.
- The multidisciplinary collaboration helped non-Coroner's staff
to better understand the Coronial process in Victoria and the
Coroner's jurisdictional duties relating to the investigation
of fall-related deaths.
- The Falls Working Party was established to devise
a standardised process for investigating reported deaths following
a fall in hospital.
As a result of this initiative, the three main objectives were
successfully achieved. Further, the relationships between the State
Coroner's Office, the members of the Falls Working Party and
other stakeholders with an interest in falls prevention were strengthened.
The Falls Working Party developed the Coroner's "Investigation
Standard" and a copy was distributed to all rural and metropolitan
public hospitals. The "Investigation Standard" was
implemented in November 2003 and is now being used to investigate
all fall-related deaths that are reported to the Coroner from
hospital.
Download the Coroner's "Investigation
Standard".  (pdf
21kb)
Three reports and journal articles were also written by CLS members
at the time of their work with the Falls Working Party. These
are:
Emmett, SL & Ibrahim, JE. The Coronial process in investigating
fall-related deaths. Journal of the Australasian Association
for Quality in Health Care 2003:13(2):6-7
Emmett, SL & Ranson, DL. Falls and fall-related injuries:
Far reaching implications. The Journal of Law and Medicine 2003;11:16-17
Coroner's Falls Working Party. The role of the Coronial
process in initiatives for the prevention of patient falls in
hospitals. Final Report from the Falls Briefing Forum 9th May,
2003
After the implementation of the "Investigation Standard" we
received a great deal of positive feedback and publicity from key
industry stakeholders.
The initiative was highly commended by the Under Secretary of
the Department of Human Services, Mr. Peter Allen. A letter
was written to the State Coroner, congratulating him and "[his]
staff on broaching this sensitive and challenging area of health".
The Coroner's "Investigation Standard" is also being
publicised around the State by other agencies. In a recent
edition of the Department of Human Service's Newsletter (Risk
Watch Volume 1, Issue 4) , an article was written that promoted
the investigation standard.
In early 2004, CLS will evaluate the effectiveness of the new
Coroner's "Investigation Standard".
It is envisaged that CLS will initiate more collaborative working
parties to standardise the Coronial investigative procedure for
other clusters of Coroner's cases. |
