Issue 27 / 28 July 2014

IN 2007, a 1-year-old South Australian boy died after the dangling cord from a window blind above his cot became wrapped around his neck.

The forensic pathologist in the case, Professor Roger Byard, told the coronial inquest death by hanging was a recognised risk when cots were put next to blinds.
Professor Byard was well placed to make that statement — he had given similar evidence in relation to the death of a 15-month-old boy in 1999.

Eight years on, you can sense the frustration in the coroner’s report that such preventable tragedies were continuing to occur, despite at least eight other coronial reports into similar deaths from around the country over the intervening years.

According to a 2013 issues paper prepared for the Australian Inquest Alliance, those reports had included recommendations about improved cord design and about public information campaigns to alert families to the danger.

So what happens to these kinds of potentially life-saving recommendations?

The short answer is that too many of them sink without a trace, lost in a bureaucratic maze or confounded by the hotchpotch of different state and territory regulations that prevent recommendations made in one jurisdiction from being implemented in another.

“The present patchwork system … means that even though coroners may be sharing information across Australia, government and other agencies in one jurisdiction are unlikely to learn effectively and in a timely way from a death, or even a pattern of deaths, in another jurisdiction”, the issues paper says.

‘This is evident even in contexts where there are clear national ramifications, such as [Aboriginal] deaths in custody.”

Infant deaths from strangulation by blind cords is another striking example, the paper says.

“Despite the risks having been raised by coroners and researchers for many years, infants have continued to die… Blind cord deaths therefore starkly demonstrate the lack of clear recommendation and implementation pathways across states and territories, together with, in most jurisdictions, few if any mechanisms to monitor the progress of recommendations, and consequently little in the way of public accountability.”

That could be an understatement. One of the few Australian studies to investigate the issue found some government authorities claimed not to be aware of coroners’ recommendations about their operations until the researchers got in touch to ask what they had done about them.

There have been some improvements since that study was published in 2008. Victoria, for example, has since 2009 required organisations receiving a coroner’s recommendation to respond with a written statement of action that is made publicly available online.

An investigation into outcomes of recommendations over the first few years of the new system in Victoria paints a mixed picture.

Just over a third (37%) of organisations said they had implemented the recommendations, while 27% rejected them and 36% said they had already taken action before receiving them (long delays in the coronial system could be a factor).

There are problems with this kind of self-reporting, of course, particularly when you consider that only 59% of recipient organisations responded to the survey. It’s probably reasonable to assume organisations that had rejected the recommendations would be less likely to respond.

For those that did respond, the most common reasons cited for rejection were that recommendations were logistically or economically unviable or that they were not relevant to the organisation’s operations.

Whatever the justice of those claims, the requirement that organisations respond publicly to coronial recommendations has to be a good thing. At the very least, it’s going to make it hard for them to claim down the track that nobody told them about it.

Even better would be a coordinated national approach to coronial recommendations, along the lines of that recommended in the Inquest Alliance paper, but we may have to wait a bit longer for that.

Jane McCredie is a Sydney-based science and medicine writer.

4 thoughts on “Jane McCredie: Deadly delays

  1. Genevieve Freer says:

    Would anyone need a coroner’s report to know that a cord blind near a cot is a strangling hazard?

    Would anyome need a coroner’s report to know that a child driving an ATV or any other vehicle is a crash hazard?

    Would anone need to know that a 4WD or truck  reversing in a driveway is a hazard to a child?

    I doubt it..

    Perhaps it is time that child nelgect was a crime.




  2. Max Kamien says:

    Coroners’ investigations are long and detailed and usually involve in-house and outside medical expertise. They usually get things right. But their reports are rarely publised, discussed or used in registrar education and training. All Coroners’ Courts are under-resourced. All badly need a savy media officer. Coroners’ findings are sent to pertinent organisations but I have never heard them discussed and rarely seen them published in medical journals or medical newsletters. That is one reason why the same recommendations eg about anaesthetic deaths in patients with short necks and doctor shoppers are so heart breakingly and repetitively common.

  3. Sue Ieraci says:

    “For those that did respond, the most common reasons cited for rejection were that recommendations were logistically or economically unviable or that they were not relevant to the organisation’s operations.” This is not uncommon, as the Coroner reports on a specific issue, and is not fully aware of either the plausibility of implementation of the recommendations, not whether they might cause more side-stream harm than they prevent. It seems rational to put Coronial recommendations through some sort of expert filter – specifically constituted for the issue at hand, to advise on both relevance/plausibility and to be tasked with implementation (or rejection, as the case many be).

  4. Graham Row says:

    It would be a very great help if coroners were required to take evidence and report upon the practical issues impacting the potential benefit of their recommendations and more importantly, the costs to the community of their implementation.  Some that I have seen over the years from a practical implementation point of view to my mind verge on the rediculous.  Safety is a commodity with a cost which the community has to bear.  The significant cost and inconvenience of a mandatory response policy should be tempered by requiring a response only to those recommendations that pass a basic cost-benefit test..  Practical implementation must be a priority  for example, consumers are swamped by so much voluminous legally required “boiler plate” legal warning information attached to consumer products these days that it is mostly ignored.

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