What do clinicians understand about deaths reportable to the Coroner?

Area of Science:

• Medical Law and Ethics
• Healthcare Quality Improvement
• Clinical Governance

Background:

• Tertiary referral hospitals play a critical role in complex healthcare delivery.
• Understanding legal reporting obligations for deaths is essential for patient safety and accountability.
• Variability in clinician knowledge can impact adherence to reporting protocols.

Purpose of the Study:

• To explore clinician understanding of deaths reportable to the Coroners Court of Victoria (CCOV).
• To identify barriers and enablers in the death reporting process.
• To inform strategies for improving compliance and patient safety.

Main Methods:

• Qualitative study involving semi-structured interviews with 22 clinicians (12 medical, 10 nursing).
• Interviews were audio-recorded, transcribed verbatim, and analyzed thematically.
• Focus on understanding reportable deaths, reasons for reporting, and associated barriers/enablers.

Main Results:

• Two primary themes emerged: lack of awareness regarding reportable deaths and a need for educational support.
• Subthemes included accountability, feedback, and blame.
• Significant variability in clinician understanding of reportable death criteria was identified.

Conclusions:

• Variable clinician understanding suggests potential under-reporting of deaths to the coroner.
• Under-reporting may lead to non-compliance with legal obligations.
• Improved education can enhance clinical practice and patient safety by leveraging lessons from reported deaths.