Government of South Australia
SA Health

File Ref: 2016-05000/1
Doc Ref: eA961411

 

 

Office of the Chief
Executive

Mr Mark 10h ns Citi Centre Building 1
1 Hindmarsh Square

State coroner Adelaide SA 5000

State Coroner's Court PO Box 287, Rundle Mall

. . . Adelaide SA 5000

302 King William Street ex 243

SA 5000 Tel 08 8226 0795 Fax 03
8226 0720 ABN 97 643 356

590


Dear MrJohns
RE: SA Health Coroner's Act Compliance Internal Audit

I am writing to provide an update on the progress of the Health Coroner's Act
Compliance Audit'.

A total of 2,102 deaths were identified in SA Public Hospitals and Health Services which
was compared to a list of deaths obtained from the State Coroner's Court Case
Management System It was confirmed that 296 SA Health inpatient deaths
were reported by SA Health to your office during the audit period 1 November 2015 to
21 April 2016.

Due to the complexity of the clinical aspects, audits were completed for a
representative sample of deaths for each Local Health Network (LHN). A total number
of 531 deaths were reviewed, which consisted of 254 patient file audits and the 296
deaths mentioned above (13 deaths were included in both numbers due to a delay in
obtaining all required data).

Independent clinical advice was provided by a Public Health Registrar from the
Department for Health and Ageing (DHA) and an Emergency Consultant from the
Flinders Medical Centre (FMC) to undertake the audit.

On 1 February 2017 my office arranged to meet with you to obtain clarification
concerning the application of Part?2A of the Consent to Medical Treatment and
Palliative Care Act (1995) as it related to this audit. This meeting was intended to also
advise you of the proposed sample size and approach. Unfortunately, we received
advice from your office on the same day that the meeting was to be cancelled and that
you were not interested in rescheduling. We proceeded as planned.

For Official Use Only-12-A2

I can now advise that the audit of 254 patient records identified two (2) deaths which
should have been reported to your office. Both met definition of the Coroner's Act
being a death "by unexpected, unnatural, unusual, violent or unknown cause".

It was determined that in both cases there were other factors that influenced the
decision making of the relevant clinicians. Following consultation it was agreed that
both would be reported to your office, which has occurred.

In addition, the audit also identified one (1) patient death relating to the reportable
death definition in the Coroner's Act 2003, whereby a death occurred ?in the course
or as a result, or within 24 hours, of the person receiving medical treatment" to which
consent has been given under Part 5 of the Guardianship and Administration Act 1993
or Part 2A of the Consent to Medical Treatment and Palliative Care Act (1995). This
patient died within 24 hours of receiving medical treatment for which third party
written consent was obtained. The treatment for which third party consent was given
did not contribute to the patient's death.

This case has also been reported to your office.

Should you have any questions regarding this audit, it scope of its findings, please do
not hesitate to contact Mr Coenraad Robberts, Group Director: Risk and Assurance
Services, on telephone

Yours sincerely

VICKIE KAMINSKI
Chief Executive

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cc: Professor Paddy Phillips, Chief Medical Of?cer, Department for Health and Ageing
Mr Coenraad Robberts, Group Director, Risk and Assurance Services