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Frequency and nature of coroners’ recommendations from injury-related deaths among nursing home residents: a retrospective national cross-sectional study
  1. Lyndal Bugeja1,
  2. Marta H Woolford1,
  3. Melissa Willoughby1,
  4. David Ranson2,
  5. Joseph E Ibrahim1
  1. 1Department of Forensic Medicine, School of Public Health and Preventive Medicine, Monash University, Southbank, Victoria, Australia
  2. 2Victoria Institute of Forensic Medicine, Southbank, Victoria, Australia
  1. Correspondence to Marta H Woolford, Department of Forensic Medicine, Health Law & Ageing Research Unit, School of Public Health and Preventive Medicine, Monash University, Southbank, Victoria 3006, Australia; marta.woolford{at}monash.edu

Abstract

Background Coroners are tasked with the investigation of unnatural and unexpected deaths. In Australia, the coroner’s role also includes making recommendations for promoting interventions to improve public safety. However, the coroners’ role in public health and safety in the aged care setting is an underexplored area of research.

Objectives To describe the frequency and nature of coroners’ recommendations for prevention of harm from injury-related deaths among nursing home residents in Australia.

Setting Accredited nursing homes in Australia.

Subjects Nursing home residents whose deaths resulted from external causes occurring between 1 July 2000 and 31 December 2013 and notified to a coroner.

Measurements Coroners’ recommendations were identified and extracted from the National Coronial Information System. Descriptive statistical techniques were used to calculate the frequency and proportion of recommendations made. The nature of recommendations was quantified using a method comprising seven elements derived from internationally accepted and applied public health conceptual models of mortality causation and prevention.

Results Coroners made recommendations about the prevention of harm in 53 of the 3289 (1.6%) external cause deaths of nursing home residents. Recommendations were most frequently made for deaths resulting from falls; however, the rate of recommendations per 1000 deaths was highest for thermal mechanisms and complications of clinical care. Most recommendations described the ‘countermeasure’ element, but rarely specified a timeframe for implementation.

Conclusion Coroners’ recommendations need to be further enhanced in the age care setting. The development of national and international guidelines on best practice in the formulation of effective recommendations should be undertaken.

  • nursing homes
  • coroners and medical examiners
  • wounds and injuries

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Footnotes

  • Contributors JEI is the senior author and contributed to the conception and development of ideas, acquisition of data, drafting and critical revision of the article draft and final approval of the version to be published. LB contributed to the conception, development and acquisition of data; analysis and interpretation of data; drafting and critical revision of the article draft and final approval of the version to be published. MHW and MW contributed to the analysis and interpretation of data, drafting and critical revision of the article draft and final approval of the version to be published. DR contributed to the design, drafting and critical revision of the article draft and final approval of the version to be published. All authors contributed substantially to the intellectual substance of the manuscript and are in full agreement regarding its content.

  • Funding Funding support for this work was provided by the Commonwealth Department of Social Services; Department of Health and Human Services, Ageing and Aged Care Branch, Victoria, Australia and Department of Forensic Medicine, Monash University. None of the funders influenced the design, methods, subject recruitment, data collections, analysis and preparation of the paper.

  • Competing interests None declared.

  • Ethics approval Approval for the study was granted by the Victorian Institute of Forensic Medicine Research Advisory Committee (RAC 011/13) on 14 April 2015, and the Department of Justice Human Research Ethics Committee granted ethics approval for access to the NCIS (CF/13/8187) on 12 May 2015.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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