It is unfortunate that NSW coronial findings are not published on Austlii or Jade, nor does there seem to be an RSS or twitter notification method for coronial publications. As a result the findings are not always easily noted, when published.

Almost 3 months ago the Inquest into the death of Jimmy James was published. The findings are of interest because of references to:

  • Non-use of “between the flags” observation charts (which were however adopted on the first day of the inquest): [176]
  • The absence of a morbidity and mortality review into the death of Mr James: [193]
  • The absence of a notification of Mr James’ death into the hospital’s Information Management System as a critical incident: [196]
  • The lack of a satisfactory response to a request for provision of evidentiary statements: [200]

The coroner’s recommendations were limited as Westmead Hospital had already modified a number of its procedures.


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