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Frequency and nature of coroners’ recommendations from injury-related deaths among nursing home residents: a retrospective national cross-sectional study


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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