Jodie Burns - Sharon Wade & Ruth Bergman - Coroners Court of Victoria - The role of the Coroners Court of Victoria when there is a reportable death during pregnancy childbirth and

The role of the Coroners Court of Victoria when there is a reportable death arising from

childbirth or the perinatal period

Coroners Court of Victoria

7th Annual Obstetric Malpractice Conference 22-23 June 2015

Rydges Hotel Melbourne,

© Coroners Court of Victoria

Presentation Outline

Jodie Burns, Senior Legal Counsel Jurisdiction, criteria for reportable deaths,

born alive rule

Ruth Bergman, Senior Clinical Nurse, Coronial Prevention Unit

Reporting a death The Medical Death Investigation

Sergeant, Sharon Wade, Police

Coronial Support Unit Inquests

Preamble - Coroners Act 2008 independently investigate reportable and reviewable deaths for the purpose of finding the causes of those deaths and

contribute to the reduction of the number of preventable deaths and the promotion of public health and safety and the administration of justice.

No Blame Jurisdiction It is not a coroner's role to determine criminal or civil liability or disciplinary matters arising from

the death under investigation e.g. coroner can not make a finding of guilt or that

someone should have their practising certificate removed or that a person receive compensation.

Mandatory findings

Section 67(1) of the Coroners Act 2008 mandates that a coroner must find, if possible:

•  Identity of the deceased •  Cause of death (medical) •  Circumstances in which death occurred.

What is a death?

Section 3 of the Coroners Act 2008

death excludes a still-birth, within the meaning of the Births, Deaths and Marriages

Registration Act 1996.

Births, Deaths and Marriages Registration Act 1996

•  Still-birth means the birth of a

still-born child •  Still-born child means a child of at least 20

weeks gestation or, if it cannot be reliably established whether the period of gestation is more or less than 20 weeks, with a body mass of at least 400 grams at birth, that exhibits no sign of respiration or heartbeat, or other sign of life, after birth.

Barrett v Coroners Court of SA

•  Case relevant because SA and Victoria have

similar criteria for jurisdiction

•  Home birth with midwife

•  Baby Tate became trapped in the birth canal.

•  At birth, baby showed no visible or aural signs of life.

•  Pulseless electrical activity (PEA) of 15 beats per minute was registered on ECG.


•  DSC applied the common law ‘born alive’ rule to determine whether the baby had achieved legal personhood and was therefore a person whose death could be the subject of a coronial investigation

•  DSC decided that he did have jurisdiction to investigate the death


•  Court of Appeal held that PEA constituted a sign of life, despite the absence of any of the recognised signs of life such as heartbeat, breathing, moving or crying.

•  There is no single indicator of life that must be present before it can be said that a baby was born alive.

•  Midwife’s application for leave to appeal to the High Court was refused.

What is a reportable death?

Step 1 - section 4 Coroners Act 2008 •  the body to be in Victoria OR •  the death occurred in Victoria OR •  the cause of death occurred in Victoria OR •  the person ordinarily resided in Victoria at

the time of the death

What is a reportable death? Step 2 – AND death is one that appears to be: q Unexpected; or q Unnatural; or q Violent, or q During a medical procedure and a registered medical

practitioner would not, immediately before the procedure was undertaken, have reasonably expected the death; or

q Following a medical procedure where the death is or may be causally related to the medical procedure and a registered medical practitioner would not, immediately before the procedure was undertaken, have reasonably expected the death

REFER TO SECTION 4 FOR FULL LIST

Medical procedure Section 3 Coroners Act 2008

medical procedure means •  a procedure performed on a person by or

under the general supervision of a registered medical practitioner and

•  includes imaging, internal examination and surgical procedure.

Relevant statistics On average 6,000+ deaths are reported to the

Coroners Court of Victoria each year

Less than 3.5% are the subject of an inquest.

It is important to note that regardless of whether an inquest is held, a coroner must

conduct a coronial investigation

Relevant statistics •  10 full-time coroners including State

Coroner •  ~ 600 investigations per coroner each

year. •  Reportable deaths allocated (randomly) to

daily duty coroner •  ~30 duty days/ year •  ~20-40/deaths reported

/day

Who assists a coroner?

•  VIFM •  ~50 full time staff •  Registrars •  Admin •  Lawyers •  Coronial Prevention Unit •  Police Coronial Support Unit •  Coroner’s investigators

Coroners Prevention Unit


Relevant sta2s2cs

2013-14 2012-13 2011-12 2010-11 2009-10

Births reported to BDM excludes stillbirths 76,357 77,701 75,188 73,039 72,254

Perinatal deaths N/A N/A 928 973 N/A

Still births recorded by CCOPMM N/A N/A 705 738 N/A

Neonatal deaths N/A N/A 223 235 N/A

Maternal death recorded by CCOPMM N/A N/A 7 10 N/A


Coronial Outcomes Justice Outcomes

–  Families feel they have been able to voice their concerns –  Practical compelling recommendations –  Publication of recommendations and responses

Health Care Outcomes

–  Families feel cared for and supported at a challenging time in their lives

–  Family referred for genetic counselling as appropriate –  Family referred for health/disease prevention counselling

as appropriate


Coroners Process Reporting of deaths

–  If no report, no independent investigation

Investigation Procedures Medical

– Clinical Context – Pathology – Public Health

Legal – Coronial inquest

Family


Coronial Admissions and Enquiries

The first week –  Reporting of death –  Gathering information –  Maternal and neonatal medical records –  GP medical records –  Placenta


VIFM Medical Examination

Cause of death

VIFM Medical Examiners Report – Preliminary examination – Forensic Pathology – Family contact – Preliminary cause of death – The Coroners Court of Victoria


Coroners Court Investigation

Establish the sequence of events

– VIFM Medical Examiners Report – Medical, ambulance records – Medical E Deposition – Police report Form 83 – Family letter concern – Statements – Expert Opinion


Common Themes

Obviously pregnant, obstetric problem Documentation Communication Challenges High BMI and associated co morbidities Gestational hypertension Adhesive placental disorders


Inquests Key Points to be aware of if you are involved in an Inquest

1. Inquisitorial court with specific statutory provisions & rules of evidence to ensure proceedings;

-‐ are comprehensible to families, friends & interested parCes -‐ allow for an apology to be made -‐ can facilitate candid evidence by providing witness immunity

2. The vital role you play as “Experts”, professional experCse, anecdotal knowledge & idenCficaCon of possible recommendaCons

3. DirecCons Hearings – effecCve use can significantly improve the impact of Inquest on all parCes


Concurrent Evidence “Hot Tub”

• Addresses, “evidence in isolation” • Format, participants & issues determined by Coroner • Aims to identify common ground & isolate differences • Benefits from –

–  Professional courtesy –  Preparation –  Recognition of hindsight bias

“In the Coroner’s investigation, the Coroner is not a source of expert knowledge but is a catalyst by which the information & conclusions of that expert knowledge can be converted to broad community use & understanding”. “The ultimate benefit which may be derived from effective use of the coroner’s process is the informing of a community & the converting of specialist knowledge & understanding to public learning, understanding & consideration of prevention”.

Hal Hallenstein, 1990


Where are we?


Resources CAE 1300 008 436 To report a death www.coronerscourt.vic.gov.au [email protected] www.vifm.org.au www.health.vic.gov.au 2011 Obesity Guideline Postnatal Care Guideline 3 Centre Consensus Guidelines www.ranzcog.edu.au Intrapartum Fetal Surveillance Management of Hypertensive Disorders Management of Obesity in Pregnancy

Questions?

Healthcare

Jodie Burns - Sharon Wade & Ruth Bergman - Coroners Court of Victoria - The role of the Coroners Court of Victoria when there is a reportable death during pregnancy childbirth and