What do clinicians understand about deaths reportable to the coroner?

Amanda Charles, Wendy Cross, Debra Griffiths

Research output: Contribution to journalArticleResearchpeer-review

4 Citations (Scopus)


Setting The study setting is a tertiary referral hospital of over 980 beds, in Victoria, Australia. The hospital is a long established major academic public health service providing healthcare, health professional education and health research. The hospital has 103,756 in-patient admissions, 190,756 outpatient attendances and over 82,000 presentations to the Emergency Department annually. Participants 22 clinicians completed an in-depth, audio-recorded interview: 12 medical and 10 nursing staff, with a variety of clinical experience. Intervention(s) Each audio recorded interview was transcribed verbatim for thematic analysis. The semi structured questions were designed to explore the clinician's understanding of deaths that meet the criteria to be reported to Coroners Court of Victoria (CCOV), and why such reporting was required. There was also the opportunity to identify any barriers or enablers to the reporting process, whether internal or external to the organisation. Results Two main themes emerged from the interviews: 1. lack of awareness of which deaths are reportable to the coroner and 2. the need for educational support. Several subthemes were also identified such as accountability, the need for feedback and blame. Discussion The understanding of clinicians as to which deaths meet the reportable criteria in healthcare is quite variable and this indicates that there might be a level of under reporting. Apart from the potential of not meeting legal obligations, there may also be the loss of a valuable opportunity for lessons to inform clinical practice and enhance the delivery of safe patient care.

Original languageEnglish
Pages (from-to)76-80
Number of pages5
JournalJournal of Forensic and Legal Medicine
Publication statusPublished - 1 Oct 2017


  • Coroner
  • Death review
  • Patient safety

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