Medicolegal Death Investigation and the Hospital (Role of the Coroner)

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Medicolegal Death Investigation and the
Hospital(Role of the Coroner)
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• Medicolegal investigation of sudden, unexplained,
  violent or unnatural deaths.

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Coroners Inquiry

• Medicolegal inquiry
• Doctor/lawyer
• Garda support
• Support from medical profession
• Relatively high postmortem rate
• Public hearing (inquest)

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Some Indicia of Coroner System.

• Comprehensive death investigation system
• Check on death certification
• Public information on safety matters
• Information in relation to mortality
• Independent investigation
• Public hearing

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• The coroner service is a public service for the
  living, which, in recognising the core value of
  each human life, provides a forensic and
  medicolegal investigation of sudden death having
  due regard to public safety and health
  epidemiology issues
• RCS 2000

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The jurisdiction of the coroner should include
the investigation not only of the medical cause
of death but also the circumstances surrounding
the death

• RCS 2000

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Medical Certificate of the Cause of Death

• Must have seen and treated the deceased within a
  month of death
• Must know the cause of death
• Death must be due to natural causes
• No concerns in relation to death

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• CAUSE OF DEATH
• I. I
• Disease or condition (a)...
• directly leading to death
• due to (or as a consequence of)
• Antecedent causes (b).
• due to (or as a consequence of)
• (c).
• II. II
• Other significant conditions

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Death Investigation

• Cause of death must be clearly formulated
• Questions of causation are very important

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• What is causation in death investigation?
• The proximate cause of death does not always
  satisfy the question of causation
• What is the proximate cause of death?

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Proximate Cause

• Eastern Health Board v Dublin City Coroner
  (Supreme Court) Nov. 2001.

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Proximate Causes

• Cardiorespiratory failure
• Hepatorenal failure
• Pulmonary oedema
• Cardiomegaly
• Post operative complications
• Septicaemia

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Incomplete Certification

• Nosocomial infection
• Pulmonary fibrosis
• Intra-cranial haemorrhage
• Multiorgan failure
• HIV and hepatitis
• Spongiform encephalopathy

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Report to Coroner

• Adverse Drug Reactions (ADR)
• Adverse event/clinical drug trial
• Alternative (herbal) Remedies

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Medical Certificate

• No unnatural cause of death

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Reportable Deaths

• Sudden deaths
• Unexplained deaths
• Difficulty in certification
• Unnatural deaths
• Violent deaths
• Suspicious deaths

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Unnatural deaths

• Road traffic collision
• Accident in the home, workplace, or elsewhere
• Any physical injury
• Falls and fractures
• Fractures in the elderly
• Drowning
• Hanging

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Unnatural deaths

• drug overdose or drug abuse
• neglect, including self-neglect
• burns or carbon monoxide poisoning
• starvation (including anorexia nervosa)
• exposure and hypothermia
• firearms injuries
• occupational disease
• food poisoning

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Extend categories of reportable deaths to include
maternal deaths and deaths of vulnerable persons

• R.31 RWGCS, Dec.2000

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Deaths Under Medical Care

• Clinically Unexplained
• May be attributable to a therapeutic or
  diagnostic procedure
• Occurs during administration of general or local
  anaesthesia
• Unexpected with regard to clinical condition of
  the patient
• Associated with allegations of lack of care (or
  serious concerns).

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Rules of practice

• BID
• death in AE department
• death within 24 hours of admission/or operation
• certain deaths in a hospital department
• maternal death
• recent transfer from nursing home, mental
  hospital or prison
• where there is any doubt as to the cause of death

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Healthcare Acquired Infection

• Occupational infections
• Blood/blood products (HCCT)
• Transfusion-associated vCJD
• Nosocomial (hospital acquired) infections

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Nosocomial (hospital acquired infection)

• Urinary tract infection
• Wound infections
• Pneumonia
• Alimentary tract infections
• Bloodstream infections
• Not routinely reportable

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Nosocomial Infections

• Hand carriage
• Hospital hygiene
• Hospital infection control
• Role of the inanimate environment

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Discuss with Coroner

• Death due to MRSA
• Death due to VRE
• Outbreaks of C.difficile infection
• Outbreaks of infection in special units

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Nosocomial infections in special units

• Gram negative Bacilli
• Coagulase-negative staphylococci
• Outbreaks reported in cardiac surgery and burns
  units, ICU and neonatal units

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Summary

• Nosocomial infections not routinely reportable
• Where cross infection and enhanced role for the
  inanimate environment are factors HAI
  reportable
• Such cases are for discussion in the first
  instance
• Clinical condition of patient/comorbidities
• Decisions will be made on an individual case basis

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Clinical Governance and Risk Management

• A crucial element is the ability to detect,
  analyse and learn from relevant experiences,
  including adverse events and service failures.

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• Clinicians must strive to achieve an audit
  record for all deaths if professional education,
  credibility and public support are to be
  maintained.
• NCEPOD 2000

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InquestPublic Policy Considerations

• (i) to determine the medical cause of death
• (ii) to allay rumours or suspicions
• (iii) to draw attention to the existence of
  circumstances which, if unremedied, might lead to
  further deaths
• (iv) to advance medical knowledge
• (v) to preserve the legal interests of the
  deceased persons family, heirs or other
  interested parties.
• Morris and Dublin City Coroner, 17th July, 2000,
  Supreme Court per Keane C.J.

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(No Transcript)
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Will NOT Investigate

• any alleged breach of a duty of care
• any damage or loss to any person resulting from
  an alleged breach
• any question of foreseeability in relation to any
  alleged damage or loss

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• The Report of the Task Force on Sudden Cardiac
  Death 2006
• Standardisation of death reporting from
  obstetrical hsopitals
• Civil Registration Act 2004 (2006)
• Emergency pandemic planning (H5N1 Avian
  Influenza)
• National Drug Related Deaths Index (HRB)

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• Coroners (Amendment) Act 2005
• Report of the Irish Council for Bioethics 2005
  (Human Biological Material/Research)
• Recommendations for collection, use and storage
  of tissue in research
• Postmortem Report (Madden) Nov. 2006

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• European Convention on Human Rights
• Jurisprudence of the European Court of Human
  Rights

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Medicolegal death investigation is a specialty in
its own right.
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• www.coronerdublincity.ie
• email coroners_at_dublincity.ie