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dc.contributor.authorMoore, Jennifer
dc.identifier.citationJennifer Moore "Coroners' recommendations about healthcare-related deaths as a potential tool for patient safety and quality of care" (2014) 127(1398) NZMJ 35.en_NZ
dc.identifier.issn1175 8716
dc.description.abstractAim To describe and investigate the nature, recipients and preventive potential of New Zealand coroners’ recommendations from 1 July 2007–30 June 2012. Method (1) A retrospective study of coroners’ recommendations during the study period was undertaken. (2) Interviews with coroners, recipients of recommendations and interested parties were conducted. Results There were 607 coronial inquiries that resulted in 1644 recommendations. There were 309 recipients of coroners’ recommendations. Government organisations received the highest proportion of recommendations (121/309). Not for profit organisations received 67 recommendations, for profit organisations received 44 recommendations and individuals received 5 recommendations. There were 72 untargeted recommendations that did not specify an identifiable organisation. The Ministry of Health received the second-highest proportion of coroners’ recommendations. Transport accidents, drowning, intentional self-harm and complications of medical or surgical care were the main underlying causes of death categories investigated by coroners. Fifty-eight of the 607 inquiries involved complications of medical or surgical care. The 123 interview participants reported that there have been improvements in coronial recommendations since the introduction of the Coroners Act 2006, but that the prophylactic and patient safety potential of recommendations is not being maximised. Conclusion Coronial investigations provide external insight into the way that our health system works and recommendations can be used as a tool to learn from preventable deaths. Given that this was the first New Zealand study of coroners’ recommendations since the introduction of the Act, more research is needed to corroborate these findings.en_NZ
dc.publisherNew Zealand Medical Associationen_NZ
dc.relation.ispartofNew Zealand Medical Journalen_NZ
dc.subjectcoroners' recommendationsen_NZ
dc.subjectpatient safetyen_NZ
dc.subjecthealthcare qualityen_NZ
dc.titleCoroners' recommendations about healthcare-related deaths as a potential tool for improving patient safety and quality of careen_NZ
dc.typeJournal Articleen_NZ
otago.schoolThe Faculty of Lawen_NZ
otago.openaccessAbstract Onlyen_NZ
dc.rights.statementMaterial in the NZMJ is available only to subscribers/NZMA members for 6 months after publication. Articles may, however, be made open access upon payment of $1000, once an article has been accepted for publication. This means the article will immediately be available to all readers online and in the pdf of the Journal. NB: All articles must first go through the review process and be accepted for publication before becoming eligible for open access.en_NZ
dc.description.refereedPeer Revieweden_NZ
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