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

Medicolegal investigation of sudden, unexplained, violent or unnatural deaths.

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

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

“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 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………………………………

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

Proximate Causes Cardiorespiratory failure Hepatorenal failure Pulmonary oedema Cardiomegaly Post operative complications Septicaemia

Incomplete Certification 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 Sudden deaths Unexplained deaths Difficulty in certification Unnatural deaths Violent deaths Suspicious deaths

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

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

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

Discuss with Coroner 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.]

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.