Transcript Medicolegal Death Investigation and the Hospital (Role of the

Medicolegal Death Investigation
and the Hospital
(Role of the Coroner)
Medicolegal investigation of sudden,
unexplained, violent or unnatural deaths.
Coroners Inquiry
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Medicolegal inquiry
Doctor/lawyer
Garda support
Support from medical profession
Relatively high postmortem rate
Public hearing (inquest)
Some Indicia of Coroner System.
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Comprehensive death investigation system
Check on death certification
Public information on safety matters
Information in relation to mortality
Independent investigation
Public hearing
“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]
“ 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]
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
CAUSE OF DEATH
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Disease or condition
(a)…………………………...
directly leading to death
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due to (or as a consequence of)
Antecedent causes
(b)…………………………….
due to (or as a consequence of)
(c)…………………………….
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Other significant conditions
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Death Investigation
• Cause of death must be clearly formulated
• Questions of causation are very important
• 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?
Proximate Cause
• Eastern Health Board v Dublin City
Coroner (Supreme Court) Nov. 2001.
Proximate Causes
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Cardiorespiratory failure
Hepatorenal failure
Pulmonary oedema
Cardiomegaly
Post operative complications
Septicaemia
Incomplete Certification
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Nosocomial infection
Pulmonary fibrosis
Intra-cranial haemorrhage
Multiorgan failure
HIV and hepatitis
Spongiform encephalopathy
Report to Coroner
• Adverse Drug Reactions (ADR)
• Adverse event/clinical drug trial
• Alternative (herbal) Remedies
Medical Certificate
No unnatural cause of death
Reportable Deaths
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Sudden deaths
Unexplained deaths
Difficulty in certification
Unnatural deaths
Violent deaths
Suspicious deaths
Unnatural deaths
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Road traffic collision
Accident in the home, workplace, or elsewhere
Any physical injury
Falls and fractures
Fractures in the elderly
Drowning
Hanging
Unnatural deaths
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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
Extend categories of reportable
deaths to include maternal deaths
and deaths of ‘vulnerable
persons’
[R.31 RWGCS, Dec.2000]
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).
Rules of practice
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BID
death in A&E 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
Healthcare Acquired Infection
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Occupational infections
Blood/blood products (HCCT)
Transfusion-associated vCJD
Nosocomial (hospital acquired) infections
Nosocomial (hospital acquired
infection)
• Urinary tract infection
• Wound infections
• Pneumonia
• Alimentary tract infections
• Bloodstream infections
[Not routinely reportable]
Nosocomial Infections
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Hand carriage
Hospital hygiene
Hospital infection control
Role of the inanimate environment
Discuss with Coroner
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Death due to MRSA
Death due to VRE
Outbreaks of C.difficile infection
Outbreaks of infection in special units
Nosocomial infections in special
units
Gram negative Bacilli
Coagulase-negative staphylococci
[Outbreaks reported in cardiac surgery and
burns units, ICU and neonatal units]
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
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.’
‘Clinicians must strive to achieve an audit
record for all deaths if professional
education, credibility and public support are
to be maintained.’
[NCEPOD 2000]
Inquest
Public 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
person’s family, heirs or other interested parties.
[Morris and Dublin City Coroner, 17th July, 2000, Supreme
Court per Keane C.J.]
Death Reported
Preliminary investigation
Investigation
Postmortem Examination
Natural Death
Coroner's Certificate
Unnatural Death
Inquest
Coroner's Certificate
Medical Certificate
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
• 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)
• 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
• European Convention on Human Rights
• Jurisprudence of the European Court of
Human Rights
Medicolegal death investigation
is a specialty in its own right.
www.coronerdublincity.ie
email: [email protected]