Frequency and nature of coroners’ recommendations from injury-related deaths among nursing home residents: a retrospective national cross-sectional study

Abstract

Coroners' recommendations need to be further enhanced in the age care setting. The development of national and international guidelines on best practice in the formulation of effective recommendations should be undertaken.

Two-Hourly Repositioning for Prevention of Pressure Ulcers in the Elderly: Patient Safety or Elder Abuse?

“…In addition, it is possible for coroners to use their statutory recommendation-making powers to direct suggestions about the prevention of PUs to RACFs (s3(e), Coroners Act 2009 (NSW)). Coroners’ recommendations are intended to prevent future deaths and therefore are essentially public health and safety interventions (Bugeja, Woolford, and Willoughby 2017 ; Moore 2016 ).…”

“…Therefore, we argue that coroners’ recommendations have the potential to prevent PUs and deaths attributable to PUs. Unfortunately, in relation to RACF deaths in Australia, coroners’ recommendations were made in less than 2 per cent for external cause of deaths (Bugeja, Woolford, and Willoughby 2017 ). The paucity of such recommendations in deaths in RACFs highlights potentially missed opportunities for the identification and promotion of injury prevention interventions (Bugeja, Woolford, and Willoughby 2017 ).…”

The contribution of domestic and family violence death reviews in Australia: From recommendations to reform?

“…Concerns about the lack of monitoring and implementation of DVDR recommendations are similar to those that have been raised about the quality and effectiveness of recommendations made by other death review bodies, such as coroners (Bugeja, Ibrahim, et al, 2012; Bugeja, Woolford, et al, 2018; Grech, 2004; Moore & Henaghan, 2014; Sutherland, Bugeja, et al, 2014; Sutherland, Studdert, et al, 2016) and child death review teams (Wirtz et al, 2011). They also mirror concerns about the efficacy of public inquiry bodies more broadly (e.g., Buckley & O’Nolan, 2013; Mintrom et al, 2021; Stark, 2019; Stutz, 2008).…”

“…First, we consider that some of the difficulties around implementation could be addressed through greater guidance and uniformity around the framing of DVDR recommendations. This could, for instance, take the form of national or international guidelines on best practice in recommendation formulation (Bugeja et al, 2018). In particular, we consider that recommendations should generally use hard framing, specify appropriate lead agencies, identify intended outcomes, nominate specific timeframes for completion and provide an indication of their implementation priority.…”