Investigation of Fall-Related Deaths in Hospitals

In May 2003, the Clinical Liaison Service (CLS) convened and facilitated a forum to review the role of the Coronial process in the investigation of fall-related deaths in hospital.

The Falls Forum and subsequently, the Falls Working Party involved a multidisciplinary team comprising:

• Coroners (Victorian State Coroner's Office)
• State Coroner's Assistants (Victorian State Coroner's Office)
• Clinical Liaison Service (Victorian State Coroner's Office)
• Researchers (National Ageing Research Institute)
• Policymakers (Department of Human Services - Aged Care)
• Quality Council (Victorian Quality Council) 
• Health service providers (Bayside Falls Prevention Projectl)
• Consumers  (Health Service Commissioner)

The aim of this collaboration was three-fold as described below:

First, the Falls Forum was convened to provide Coroner's Office staff with a general overview of the current research initiatives, practice changes and administrative systems that are used for the prevention and management of patient falls in hospital.

Second, the multidisciplinary collaboration helped non-Coroner's staff to better understand the Coronial process in Victoria.  The Coroner's jurisdictional duties with regard to the investigation of fall-related deaths were fully elucidated.

Third, the Falls Working Party was established to devise a standardised process for investigating reported deaths following a fall in hospital.

As a result of this initiative, the three main aims were successfully achieved.  Further, the relationships between the State Coroner's Office, the members of the Falls Working Party and other key stakeholders with an interest in falls prevention were strengthened. 

The Falls Working Party developed the Coroner's “Investigation Standard” and distributed a copy to all rural and metropolitan public hospitals.  The “Investigation Standard” was implemented in November 2003 and is now being used to investigate all fall-related deaths that are reported to the Coroner from hospital. 

Three reports and journal articles were also written by CLS members at the time of their work with the Falls Working Party.  These are:

Emmett, SL & Ibrahim, JE. The Coronial process in investigating fall-related deaths. Journal of the Australasian Association for Quality in Health Care 2003:13(2):6-7

Emmett, SL & Ranson, DL.  Falls and fall-related injuries: Far reaching implications. The Journal of Law and Medicine 2003;11:16-17

Bohensky M, Emmett SL, Ibrahim JE & Ranson DL. Experience With Practice Guidelines For Medico-Legal Death Investigations: The case of falls-related deaths in hospital. Med Law. In Press.

After the implementation of the “Investigation Standard” we received a great deal of positive feedback and publicity from key industry stakeholders. 

The initiative was highly commended by the Under Secretary of the Department of Human Services, Mr. Peter Allen.  A letter was written to the State Coroner, congratulating him and “[his] staff on broaching this sensitive and challenging area of health”.

The Coroner's “Investigation Standard” is also being publicised around the State by other agencies.  In a recent edition of the Department of Human Service's Newsletter (Risk Watch Volume 1, Issue 4), an article was written that promoted the investigation standard. 

CLS is now convening a working party to standardise the Coronial investigative procedure for cases involving the communication of abnormal radiological findings.

The can be downloaded as a PDF.

The Coroner's "Investigation Standard"  can be downloaded as a PDF .