Coronal findings regarding hospital systems

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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