Residential Aged Care Coronial Communique

The Residential Aged Care Coronial Communiqué highlights selected cases that have been reported to the State Coroner's Office and are of interest to the Aged Care Community. The aims of the Communiqué are:

• To improve the awareness of clinicians, health workers, carers and those in positions of governance about adverse events resulting from systems failures. Lessons from past cases can then be applied to their own institutions.

• To improve residential aged care workers' understanding of the coronial system and the work performed by the Clinical Liaison Service.

The Communiqué will be produced quarterly and distributed electronically to subscribers who have registered their interest with the publication team. Subscription is free of charge and can be sent to your preferred email address. To be added to our distribution list, please email racc@vifm.org and request to be added to the Residential Aged Care Coronial Communiqué list.

What's New?

The latest edition of the Residential Aged Care Coronial Communiqué (June 2009) is now available:

This edition marks the 10th edition of the Residential Aged Care CommuniquéThe focus of this issue is to consolidate the learning from the previous four clinical topics covered: wound care; diabetes mellitus; warfarin and pneumonia.

27 seconds download via 56K modem RACCC Issue 10

The Clinical Liaison Service have provided a template to assist contributors to explain how the Residential Aged Care Coronial Communiqué has assisted to change practice in your facility. Please access this template here:-

RACC Feedback Template

Other Publications:

An informatic and referenced discussion on 3 seconds download via 56K modem Choking and Nutrition in RAC residents is available here and a 1 second download via 56K modem List of Key Issues that Residential Aged Care Facilities Need to Address is available here.

Previous Editions:

27 seconds download via 56K modem RACCC Issue 9 (March 2009)

This edition focuses on deaths caused by pneumonia which are usually considered to be a natural cause death. Prevention of natural cause deaths requires us to closely examine the clinical situation as it is not always obvious what could be done better.

27 seconds download via 56K modem RACCC Issue 8 (December 2008)

This edition examines warfarin, a commonly prescribed medication and a potentially lethal pharmaceutical product.
Three cases highlight systems issues, including effective communication and co-ordination of care: the complexity of managing warfarin with the need for regular laboratory testing; close monitoring of the dose; being prepared for responding to 'out of range' results; and adhering to protocols and awareness of common drug interactions.
Resources and an expert commentary are also included ina contribution jointly written by a haematologist and a pharmacist.

27 seconds download via 56K modem RACCC Issue 7(September 2008)
This edition of the Communiqué focuses on the very common and challenging chronic condition of diabetes mellitus. Three cases demonstrate the need for having systematic approaches to managing residents with diabetes mellitus. The cases also demonstrate the nature of emergencies and complications that may occur. Practical information drawn from the experiences of a diabetes educator who successfully implemented changes in residential aged care settings is also provided.

27 seconds download via 56K modem RACCC Issue 6 (June 2008) This edition focuses on the issue of pressure ulcers and presents three cases along with two short reports about the research evidence base and current practice in the prevention, recognition and management of pressure ulcers.

RACC Issue 5 (April 2008) reminds and refreshes memories about the lessons learnt from the preceding four issues about the prevention of deaths from physical restraints, falls, choking and gaps in the interfaces of care.

51 seconds download via 56K modem RACC Issue 4 (February 2008) explores the challenges of the interfaces between aged care facilities and families, hospitals, general practitioners and emergency departments. The supplementary articles are available here:
12 seconds download via 56K modem Supplementary Articles (Vol 3 Iss 1: February 2008)
References for commentary:
6 seconds download via 56K modem References (Vol 3 Iss 1: Feb 2008)

36 seconds download via 56K modem RACC Issue 3 (June 2007) addresses the subject of Choking and Nutrition in Residential Aged Care residents

32 seconds download via 56K modem RACC Issue 2 (March 2007) and the full copy of Keith Hill's article can be accessed here Keith Hill's Falls Article

1 second download via 56K modem RACC Issue 1 (October 2006) - the first edition of the Residential Aged Care Coronial Communique