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A CALL for all doctors to have access to coroners’ guidelines to help them correctly identify reportable deaths has been welcomed, but a leading health law expert has warned that more significant reform is needed.
Professor David Studdert, professor of law and medicine, said if all states had coroners’ guidelines for reporting deaths that occur in hospital or other medical settings it would help make the best of a “less-than-ideal situation”.
“A more significant fix would be for the jurisdictions — separately or collaboratively — to take a hard look at the formulation of the medical death reporting rules themselves”, said Professor Studdert, previously based at the University of Melbourne and now at Stanford University in the US.
Professor Studdert was commenting on an MJA article calling for the development of coroners’ guidelines in all jurisdictions. Guidelines are currently only available in Queensland, NSW and Victoria. (1)
The authors wrote that even with the best model of legislative definitions around the circumstances in which medical-setting deaths must be reported, doctors still had to apply these to each case to determine if a death was reportable.
“It is not realistic to expect doctors, and often junior ones at that, to engage in this kind of legal analysis without further guidance or assistance”, they wrote.
They used a hypothetical case of a 23-year-old woman with cystic fibrosis who died after a delay in the removal of a clamped chest drain, to highlight the variances between state laws and the difficulties in applying these laws.
Professor Studdert told MJA InSight the statutory rules in some jurisdictions regarding what types of medical deaths must be reported were “just too vague to produce consistent reporting”.
“Another problem is that some jurisdictions call for the reporting of certain types of care-related deaths but not others, and the distinctions between reportable and non-reportable deaths do not make a lot of sense from a patient safety perspective”, he said, adding that there was too much variation across jurisdictions on the types of medical deaths that must be reported.
“At a time when the practice of medicine is increasingly a national enterprise, this is undesirable”, he said.
Associate Professor David Ranson, deputy director of the Victorian Institute of Forensic Medicine, said it was very difficult to design a set of legal phrases that was capable of being unambiguous in a medical setting.
“Even though the law tries to define [reportable deaths] — and does a reasonably good job — to a doctor viewing it through a medical set of eyes, there remain some significant problems in understanding [those definitions]”, Professor Ranson told MJA InSight.
The development of guidelines was important, but he cautioned that they would only ever provide guidance.
“Guidance can certainly help but … it doesn’t absolve the doctor from the legal requirements. What is straightforward to a lawyer … may not be straightforward to a doctor in the clinical situation with the huge variability of clinical presentations”, he said.
The golden rule was “if in doubt, report”, said Professor Ranson, pointing to a study he coauthored highlighting the underreporting of deaths in Victoria. (2)
He also advised doctors that support was readily available from the coroner’s office.
AMA vice president Dr Stephen Parnis said coroners’ guidelines were useful in helping doctors to navigate this complex area of medicine and law, and agreed that discussing cases with the coronial services should be encouraged.
“The law in this area … can be complex, so it’s not surprising that doctors don’t readily profess to have a comprehensive knowledge about [reportable deaths]”, Dr Parnis told MJA InSight. “That’s where I think there is real value in guidelines and also simple, practical things like the ability to discuss a clinical case with the coronial service.”
Dr Parnis said it was important for junior doctors to be supported by senior clinicians in these often complex decisions and, in his experience, this was usually the case.
“The notion of a cause of death or whether a death [was] expected or not … [is] often a fairly difficult decision that requires not only expertise, but a lot of experience.”
He said clinicians also had to balance the “incredibly valuable role” of the coroner in terms of understanding causes of death and making recommendations, with the added stress caused to families by referring a case.
1. MJA 2014; Online 8 December
2. MJA 2013; 199: 402-405
(Photo: Photographee.eu / Shutterstock)
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We had the fortunate situation in the Great Southern region of Western Australia where sudden unexpected deaths due to presumed natural causes could have their autopsies performed in the regional centre. This meant the local doctors could sometimes get informal feedback on cause of death before the full report was even completed. Unfortunately this could not continue when the new hospital was built and the old one demolished. Why? Because the regional hospital up-grades do not have autopsy rooms.
When I was training we were given instruction about what were coroners cases and often ended up ringing the “coroners constable’ at all times of day or night, trying to give details to a non medical person who would pass it on to the coroner ( again usually a lawyer rather than a doctor) I thought this was incongruous at the time and still do. The very fact that the coroner is a lawyer introduces an adversarial legal aspect to the cases.
Trying to get information about autopsy results in a short time frame was nigh impossible and junior doctors often had moved on to other units by the time these were obtained– educational opportunity lost. There was a secretive ,adversarial approach from the Coroner’s office at times.
A more collaborative and uniform approach from Coroners offices, and access to autopsy results in a reasonable time frame are badly needed.