Hospitals have been found to hide suspect deaths from the Coroner

VICTORIAN hospitals failed to report potentially suspect or preventable deaths in a widespread shunning their legal requirements, an investigation has revealed.

VICTORIAN hospitals have failed to report potentially suspect or preventable deaths in a widespread shunning their legal requirements.

An investigation has found one in 15 reportable deaths are not being referred to Victoria’s coroner, violating the state’s legal processes and denying authorities the chance to investigate for potential safety issues or to uncover foul play.

Hospitals were found responsible for almost 70 per cent of the hidden deaths, however their failure to report them was largely due to misunderstandings rather than deliberate acts, the report commissioned by the Coronial Council revealed.

ONE IN 10 SURGICAL DEATHS NON-RISK PATIENTS

RISING MEDICAL MISTAKES CAUSE ONE DEATH A WEEK

VICTIM HAD CODE DOWNGRADED, INQUEST HEARS

Victorian Health Minister Jill Hennessy. Picture: Stefan Postles

Health Minister Jill Hennessy has accepted some of the 22 recommendations to improve processes and procedures for reporting potentially problematic deaths, but said further consideration was required to determine of legislative reforms was needed for others.

“It’s essential the Coroner can investigate potentially avoidable deaths, so that where possible lessons can be learned, to reduce the likelihood of recurrence. We’ll take the necessary steps to plug any gaps in reporting,” she said.

“The policies and procedures that dictate whether or not a death should be reported to the coroner are outdated and confusing.

“We’re fixing that, and we’ll work with clinicians to ensure they understand their obligations.”

As well as suicides, overdoses and homicides, Victorian law requires all “unnatural deaths” due to road crashes, workplace deaths, drownings, and animal attacks to be reported to the coroner.

Hospital deaths during a medical procedure, or following a procedure where the patients was not expected to die, must also be reported so the coroner can determine whether they could have been prevented.

The investigation ordered by the Coronial Council and undertaken by KPMG found that although Victoria’s system for reporting deaths was “broadly functional” it suffered from inappropriate and under reporting.

It found 6.6 per cent of mandatory reportable deaths were not forwarded to the coroner. Further examination of cases referred by the Registry of Births, Deaths and Marriages found that of the 320 cases that should have been reported, 309 had the cause of death changed when investigated.

Safer Care Victoria chief executive officer Prof Euan Wallace.

As well as determining an individual cause of death, Safer Care Victoria chief executive officer Prof Euan Wallace said the coroner were vital in highlighting wider issues across the health system.

“There is no purposeful witholding or reporting, it is really around clinicians awareness of what should and should not be reported,” he said.

“We do not know that they were all preventable, all we know is they the fell into a category that merited some review because they were unexpected etc.”

Under reforms already accepted Safer Care Victoria will be notified of all relevant hospital deaths, hospitals will nominate a single point of contact to receive information about deaths, and doctors will receive training and resources to reinforce what constitutes a reportable death.