Justin Curran, FACEM, Registrar; David McD Taylor, FACEM, Director of Emergency and General Medicine Research.
National Coroners Information System: A valuable source of lessons for emergency medicine
Version of Record online: 1 JUN 2012
© 2012 The Authors. EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Emergency Medicine Australasia
Volume 24, Issue 4, pages 442–450, August 2012
How to Cite
Curran, J. and McD Taylor, D. (2012), National Coroners Information System: A valuable source of lessons for emergency medicine. Emergency Medicine Australasia, 24: 442–450. doi: 10.1111/j.1742-6723.2012.01575.x
- Issue online: 2 AUG 2012
- Version of Record online: 1 JUN 2012
- Manuscript Accepted: 19 APR 2012
- emergency department;
- risk management
To interrogate the National Coroners Information System (NCIS) to determine the recurrent themes among coroners’ recommendations that aimed to increase the safety of ED care.
This was a retrospective analysis of NCIS closed cases, from Queensland, New South Wales, Tasmania, Victoria, Australian Capital Territory, South Australia and North Territory, entered since its inception in 2000. The keyword ‘emergency department’ returned 1645 cases, of which 180 were found to be relevant. The primary outcomes were the number and nature of cases where recommendations for improvements in ED care had been made and the recurrent themes of these recommendations that could inform education initiatives.
Of the 180 cases, 108 (60.0%) were of deceased men and subject age ranged from 2 days to 91 years. The commonest causes of death were trauma (26.7%), infection (24.4%), cardiac events (15.0%) and poisoning (8.9%). No coronial recommendations were required in 19 cases. For the remainder, recommendation themes related to issues of risk management/medico-legal, diagnostic/therapeutic error, education, documentation/communication and re-presentation. The themes associated with the different doctor designations (consultant, registrar, resident/intern) were similar, although registrars and residents/interns tended towards more diagnostic/therapeutic errors. The themes associated with hospital type (referral, urban, regional/rural) were also similar. Although theme analysis is important, some individual cases were particularly instructive.
The NCIS data theme analysis indentifies important high-risk patients and presenting complaints. These should be incorporated into emergency physician training. EDs should review the coronial recommendations to ensure that, where possible, they have been adopted.