Benefit of hindsight: systematic analysis of coronial inquest data to inform patient safety in hospitals
Val Pudney A and Carol Grech A BA School of Nursing and Midwifery, University of South Australia, City East Campus, North Terrace Adelaide, SA 5000, Australia. Email: val.pudney@unisa.edu.au
B Corresponding author. Email: Carol.Grech@unisa.edu.au
Australian Health Review 40(4) 371-377 https://doi.org/10.1071/AH15020
Submitted: 29 January 2015 Accepted: 17 August 2015 Published: 12 October 2015
Abstract
Objective The aim of the present study was to explore the potential of coronial inquest data to inform patient safety improvement in hospitals at a system level.
Methods A retrospective analysis of 20 years of South Australian (SA) coronial inquest findings was performed using both qualitative content analysis methods and statistical descriptive analyses.
Results In all, 113 cases were analysed. More than one-third of deaths (39%) were associated with emergency care. Analysis revealed 11 recurrent themes and two notable contributing factors that highlighted specific areas of concern for SA hospitals over that time period. The most common action recommended by coroners (49.6%; n = 56 cases) was the review or development of policy, protocol, procedure or guidelines designed to improve patient care. In almost one-quarter (24%) of deaths reviewed, coroners alerted health authorities to poor standards of care and/or instructed individual clinicians to review the standard of their clinical practice.
Conclusions The analysis provided a retrospective review of coronial inquest data associated with hospital care over a 20-year period. The findings highlight specific areas of concern for patient safety over that time. More broadly, this analysis contributes to an emerging body of evidence in the Australian academic literature that demonstrates the value of systematic analysis of coronial data at a system level to inform patient safety improvement in Australian healthcare.
What is known about the topic? Australian coroners have an important role to play in public health and safety. Many areas of social inquiry across Australia use coronial inquest data to identify recurrent hazards and assist in the development of relevant social policy. However, there is very little research reported in the academic literature that associates analyses of coronial data with patient safety improvement in healthcare. Although coronial recommendations made from individual cases of avoidable death are considered by health authorities, there is no evidence in the academic or grey literature that any systematic analysis of coronial inquest data is undertaken at a national or state or territory level to contribute to patient safety improvement. The few cases that are reported in the Australian academic literature provide valuable evidence of the benefits in terms of identifying recurrent hazards and prompting practice change.
What does this paper add? This paper provides a descriptive overview of 20 years of coronial inquest data associated with hospital care in one Australian state. It provides evidence of recurrent themes and noteworthy contributing factors that highlight specific areas of concern for patient safety in hospitals. The methods used in the analysis can be applied across other settings in Australian healthcare. In addition, the paper adds to an emerging body of research evidence in the Australian academic literature illustrating the benefits of reviewing coronial inquest data to inform patient safety initiatives.
What are the implications for practitioners? Findings from this analysis can be used to further the knowledge and understanding of health practitioners working in hospital settings as to the type of patients, clinical incidents and medical management issues that have featured repeatedly in avoidable deaths reported by coroners.
Additional keywords: acute care, avoidable deaths, coroner, systematic analysis, longitudinal data, practitioner education.
References
[1] Freckelton IR. Death investigation, the coroner and therapeutic jurisprudence. J Law Med 2007; 15 242–53.[2] Bray RS. Death scene jurisprudence: the social life of coronial facts. Griffith Law Rev 2010; 19 567–92.
| Death scene jurisprudence: the social life of coronial facts.Crossref | GoogleScholarGoogle Scholar |
[3] Bray RS. Coronial law reform. Altern Law J 2010; 35 232–3.
[4] Bohensky M, Ibrahim JE, Ranson D. Re-inventing the wheel? Med J Aust 2005; 183 546
| 16296979PubMed |
[5] Van Der Weyden MB. The Bundaberg Hospital scandal: the need for reform in Queensland and beyond. Med J Aust 2015; 183 284–5.
[6] National Coronial Information System (NCIS). Fact Sheets. Melbourne: NCIS; 2010–2014; Available at: http://www.ncis.org.au/category/ncis-mortality-publications/ [verified 3 March 2015].
[7] National Coronial Information System (NCIS). National Coroners Information System annual report 2011–2012. Melbourne: NCIS; 2012.
[8] National Coronial Information System (NCIS). NCIS annual report 2012–2013. Melbourne: Victorian Department of Justice; 2013.
[9] Moore J. Coroners’ recommendations about healthcare-related deaths as a potential tool for improving patient safety and quality of care. N Z Med J 2014; 127 35–53.
| 25146860PubMed |
[10] SA Health. South Australian patient safety report 2012–2013. Adelaide: Government of South Australia; 2014.
[11] Government of Western Australia Department of Health. Your safety in our hands in hospital. Perth: WA Department of Health; 2013.
[12] Department of Health Victoria. Sentinel event program: annual report. Melbourne: Victorian Department of Health; 2002–2011. Available at: http://www.health.vic.gov.au/clinrisk/publications/sentinel-anrep.htm [verified 20 November 2013].
[13] Federation of Community Legal Centers (Victoria) Inc. Saving lives by joining up justice: why Australia needs coronial reform and how to achieve it. Melbourne: Australian Inquest Alliance; 2013.
[14] Government of Western Australia (Patient Safety Surveillance Unit). From death we learn. Perth: Department of Health, Government of Western Australia; 2013.
[15] Coroners Court of Victoria. Coroners prevention unit. Melbourne: Coroners Court of Victoria; 2013. Available at: http://www.coronerscourt.vic.gov.au/home/coronial+investigation+process/brochure+-+coroners+prevention+unit [verified 30 April 2014].
[16] Curran J, McD Taylor D. National Coroners Information System: a valuable source of lessons for emergency medicine. Emerg Med Australas 2012; 24 442–50.
| National Coroners Information System: a valuable source of lessons for emergency medicine.Crossref | GoogleScholarGoogle Scholar | 22862763PubMed |
[17] Ibrahim JE, Ehsani JP, McInnes JA. The effect of printed educational material from the Coroner in Victoria, Australia, on changing aged care health professional practice: a subscriber survey. J Am Geriatr Soc 2010; 58 585–91.
| The effect of printed educational material from the Coroner in Victoria, Australia, on changing aged care health professional practice: a subscriber survey.Crossref | GoogleScholarGoogle Scholar | 20398124PubMed |
[18] Grech C. Coronial inquiries into fatal adverse events in South Australian hospitals: from inquest to practice. Department of Public Health, University of Adelaide, PhD; 2004.
[19] Thomas DR. A general inductive approach for analyzing qualitative evaluation data. Am J Eval 2006; 27 237–46.
| A general inductive approach for analyzing qualitative evaluation data.Crossref | GoogleScholarGoogle Scholar |
[20] Department of Health Victoria. Sentinel event program. Melbourne: Department of Health Victoria; 2014. Available at: http://health.vic.gov.au/clinrisk/sentinel/index.htm [verified 28 August 2015].
[21] SA Health. South Australian patient safety report 2010–2011. Adelaide: SA Health; 2012.
[22] SA Health. South Australian patient safety report 2011–2012. Adelaide: SA Health; 2013.
[23] National Coronial Information System. Data dictionary for the National Coronial Information System, version 3. 2010. Available at: http://www.ncis.org.au/wp-content/uploads/2013/04/Data-Dictionary_Version-3.pdf [verified 15 October 2013].
[24] Nygren M, Roback K, Öhrn A, Rutberg H, Rahmqvist M, Nilsen P. Factors influencing patient safety in Sweden: perceptions of patient safety officers in the county councils. BMC Health Serv Res 2013; 13 52
| Factors influencing patient safety in Sweden: perceptions of patient safety officers in the county councils.Crossref | GoogleScholarGoogle Scholar | 23391301PubMed |
[25] Organisation for Economic Cooperation and Development. Surgical complications. Health at a glance 2013: OECD indicators. OECD Publishing; 2013.
[26] World Health Organization (WHO). Human factors in patient safety: review of topics and tools. 2009. Available at: http://www.who.int/patientsafety/research/methods_measures/human_factors/human_factors_review.pdf [verified 20 October 2013].
[27] Vincent C. Understanding and responding to adverse events. N Engl J Med 2003; 348 1051–6.
| Understanding and responding to adverse events.Crossref | GoogleScholarGoogle Scholar | 12637617PubMed |
[28] Australian Institute of Health and Welfare (AIHW), Australian Commission on Safety and Quality in Health Care (ACSQHC). Sentinel events in Australian public hospitals 2004–05. Catalogue no. HSE.51. Canberra: AIHW; 2007.
[29] Orman SA, Thornton VJ. Analysis of junior doctor supervision in Australasian emergency departments. Emerg Med Australas 2010; 22 301–9.
| 20629699PubMed |
