The impact of a clinical team assisting the Coroner’s investigation of healthcare-related deaths: Reflections on six-years of service

References 

1. De Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17:216–223
   • CrossRef
2. Wilson RM, Runciman WB, Gibberd RW, et al. The Australian quality in health care study. Med J Aust. 1995;163:458–471
   • MEDLINE
3. Ehsani JP, Jackson T, Duckett S. The incidence and cost of adverse events in Victorian hospitals 2003–2004. Med J Aust. 2006;184:551–555
   • MEDLINE
4. Corrigan JM, Donaldson MS, Kohn LT, Maguire SK, Pike KC. Crossing the quality chasm: a new health system for the 21st century. Committee on quality of health care in America, Institute of medicine. Washington, DC: National Academy Press; 2001;
5. Department of Health. An organisation with a memory: report of an expert group on learning from adverse events in the NHS. London: The Stationery Office; 2000.
6. National Expert Advisory Group on Safety and Quality in Australian Health Care 1998. Final report to the Hon Dr. Michael Wooldridge MP, Minister for Health and Family Services. Commonwealth of Australia: Australia; 1998.
7. Australian Council for Quality and Safety in Health Care. Safety and quality council action plan. Commonwealth of Australia. Available from: http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/a-zpublicationsm-o#O; 2001 [accessed 8.12.01].
8. Luce T, Hodder E, McAuley D, Berry C, Heaton-Armstrong A, Sacranie IAKM. Death certification and investigation in England, Wales and Northern Ireland: the report of a fundamental review (Cm 5831, 2003). Norwich: Crown. Available from: www.archive2.official-documents.co.uk/document/cm58/5831/5831.pdf; 2003 [accessed 8.12.03].
9. Ibrahim JE, McMillan N, Grech C, Bugeja L, Ranson D. The role of the Coronial process in initiatives for improving patient safety and quality of health care: final report of a consultancy into the Coronial death investigation process in Australia: its role in reviewing the safety and quality of health care provision. Victorian institute of forensic pathology Southbank, Victoria, Australia May 2003. Report submitted to the Australian Council for Safety and Quality in Health Care, Commonwealth Department of Health and Ageing Canberra, Australia.
10. Victorian Parliament Law Reform Committee. Coroner’s act 1985: discussion paper. Melbourne: Parliament of Victoria. Available from: http://www.parliament.vic.gov.au/lawreform/inquiries/Coroners%20Act/; 2005 [accessed 00.6.06] .
11. National Public Health Partnership. The Planning Framework for Public Health Practice. September 2000, Victoria, Australia. Available from: www.nphp.gov.au/publications/phpractice/planfrwk.pdf.
12. Victorian Institute of Forensic Medicine. Available from: http://www.vifm.org.
13. Bohensky M, Ibrahim JE, O’Brien A, Emmett SL, Charles A, Young C, et al. World without borders: integrating clinical perspectives into the Coronial Jurisdiction in Victoria, Australia. Med Law J. 2006;25:13–29
14. O’Brien A. Preliminary results of the first 100 cases reviewed by the CLS. Mortality review: Dead or Alive? Investigating hospital death reviews. Image Capital Seminar Victorian Institute of Forensic Medicine, Melbourne, Victoria, 7 June 2005. Available from: http://www.vifm.org/cgi-bin/getObject.cgi?id=o410.
15. Bohensky M, Ibrahim JE, O’Brien A, Ranson DL. The experience of a medical investigation unit within the Coroners’ system. International Society for Quality in Health Care’s 23rd International Conference, October 22nd–25th 2006 QE II Centre Westminster London England. Available at <www.isqua.org/isquaPages/Conferences/London/AbstractsSlides/DISPLAYS/256%20-%20Bohensky.pdf>.
16. O’Brien A, Cunningham N, Ibrahim JE, editors. Coronial Communiqué [electronic resource]: Clinical Liaison Service–Connecting Clinicians with Coroners. Southbank, Victoria. State Coroners Office; Victorian Institute of Forensic Medicine. Available from: http://www.vifm.org/communique.html.
17. Ibrahim JE, Nay R, editors. Residential aged care Coronial communiqué [electronic resource]: clinical liaison service. Southbank, Victoria. State Coroners Office; Victorian Institute of Forensic Medicine. Available from: http://www.vifm.org/n962.html.
18. Ibrahim JE, Ehsani JP. The impact of the Coronial communiqué on changing patient safety: a subscriber survey. Australian Health Review; 2008 [accepted 10.12.08].
19. Ibrahim JE, Ehsani JP. The impact of the printed educational material from the Coroner/medical examiner on changing clinical practice: a subscriber survey. Submitted Journal American Geriatric Society.
20. Charles A, Ranson D, Bohensky M, Ibrahim JE. Under-reporting of deaths to the Coroner in two public hospitals in Victoria, Australia. Int J Qual Healthcare. 2007;19:232–236
21. Clinical Liaison Service. Mortality review: Dead or Alive? Investigating hospital death reviews. Image Capital Seminar Victorian Institute of Forensic Medicine, Melbourne, Victoria, 7 June 2005. Available from: http://www.vifm.org/conference.html.
22. Emmett SL, Ibrahim JE. An open day at the Coronial services centre: bridging the gap between health care providers and death investigators. J Aust Assoc Qual Health Care. 2003;13:15–16
23. Bohensky M, Emmett SL, Ibrahim JE, Ranson D. Experience with practice guidelines for medico-legal death investigations: the case of falls-related deaths in hospital. Med Law J. 2005;24:727–742
24. Ibrahim JE, Ranson DL, O’Brien A, Charles A, Young C. Forensic investigation of medical treatment related Deaths. Leg Med. 2009;11:S71–S75
25. Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews. 2006;(2):[Art. No.: CD000259]
26. Farmer AP, Légaré F, Turcot L, Grimshaw J, Harvey E, McGowan JL, et al. Printed educational materials: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2008;(3):[Art. No.: CD004398]
27. Doumit G, Gattellari M, Grimshaw J, O’Brien MA. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2007;(1):[Art. No.: CD000125]
28. O’Brien MA, Rogers S, Jamtvedt G, Oxman AD, Odgaard-Jensen J, Kristoffersen DT, et al. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2007;(4):[Art. No.: CD000409]
29. Western Australia, Department of Health, Office of Safety and Quality in Health Care. From Death we learn: Lessons from the Coroner Department of Health 2006. Available from: http://www.health.wa.gov.au/publications/subject_index/a-z_index.cfm#f; 2006 [accessed 18.12.08].
30. Impact Consulting Group. Review of the Clinical Liaison Service Final Report December 2004. Department of Justice, Victoria. [Department of Justice internal document].
31. PricewaterhouseCoopers Economic Benefits of the National Coroners Information System (NCIS) Victorian Institute of Forensic Medicine March 2003. [Internal VIFM document].
32. Garling P. Final report of the special commission of inquiry: acute health services in NSW public hospitals overview. Sydney NSW Government 27th November 2008. Available from: http://www.lawlink.nsw.gov.au/lawlink/Special_Projects/ll_splprojects.nsf/vwFiles/E_Overview.pdf/$file/E_Overview.pdf.