Benefit of hindsight: systematic analysis of coronial inquest data to inform patient safety in hospitals
Authors: Pudney Val , Grech Carol 
Published: October 2015

Objective The aim of the present study was to explore the potential of coronial inquest data to inform patient safety improvement in hospitals at a system level. Methods A retrospective analysis of 20 years of South Australian (SA) coronial inquest findings was performed using both qualitative content analysis methods and statistical descriptive analyses. Results In all, 113 cases were analysed. More than one-third of deaths (39%) were associated with emergency care. Analysis revealed 11 recurrent themes and two notable contributing factors that highlighted specific areas of concern for SA hospitals over that time period. The most common action recommended by coroners (49.6%; n = 56 cases) was the review or development of policy, protocol, procedure or guidelines designed to improve patient care. In almost one-quarter (24%) of deaths reviewed, coroners alerted health authorities to poor standards of care and/or instructed individual clinicians to review the standard of their clinical practice. Conclusions The analysis provided a retrospective review of coronial inquest data associated with hospital care over a 20-year period. The findings highlight specific areas of concern for patient safety over that time. More broadly, this analysis contributes to an emerging body of evidence in the Australian academic literature that demonstrates the value of systematic analysis of coronial data at a system level to inform patient safety improvement in Australian healthcare. What is known about the topic? Australian coroners have an important role to play in public health and safety. Many areas of social inquiry across Australia use coronial inquest data to identify recurrent hazards and assist in the development of relevant social policy. However, there is very little research reported in the academic literature that associates analyses of coronial data with patient safety improvement in healthcare. Although coronial recommendations made from individual cases of avoidable death are considered by health authorities, there is no evidence in the academic or grey literature that any systematic analysis of coronial inquest data is undertaken at a national or state or territory level to contribute to patient safety improvement. The few cases that are reported in the Australian academic literature provide valuable evidence of the benefits in terms of identifying recurrent hazards and prompting practice change. What does this paper add? This paper provides a descriptive overview of 20 years of coronial inquest data associated with hospital care in one Australian state. It provides evidence of recurrent themes and noteworthy contributing factors that highlight specific areas of concern for patient safety in hospitals. The methods used in the analysis can be applied across other settings in Australian healthcare. In addition, the paper adds to an emerging body of research evidence in the Australian academic literature illustrating the benefits of reviewing coronial inquest data to inform patient safety initiatives. What are the implications for practitioners? Findings from this analysis can be used to further the knowledge and understanding of health practitioners working in hospital settings as to the type of patients, clinical incidents and medical management issues that have featured repeatedly in avoidable deaths reported by coroners.