24-08-10
Catherine Henry Partners Lawyers Newcastle
What is a Coronial inquest?
An inquest is an investigation into a person’s death conducted by the Coroner. Except in special circumstances, it is a public hearing.
When the Coroner decides to hold an inquest, any person with sufficient interest in the subject matter of proceedings may appear in person or be legally represented the inquest. Any person who is a relative of the deceased will be entitled to appear or be represented at the inquest other than in exceptional circumstances.
The purpose of a coronial inquest is to determine both the manner and cause of death. It is important to realise that the Coroner does not make a finding as to guilt or innocence and is generally required to refrain from making a finding in such a way as to appear to determine civil or criminal liability. Thus, where the Coroner’s findings suggest there may have been negligence on the part of any person, it is up to the relatives of the deceased to take any appropriate action.
Comments and recommendations about public health or safety are also part of the Coroner’s findings. Coronial recommendations are generally referred to the responsible government department or agency.
When is an inquest held?
Some instances in which the Coroner may decide to hold an inquest include when a person dies:
- a sudden death the cause of which is unknown;
- in circumstances where they had not been attended by a medical practitioner for six months immediately prior to their death;
- where the death was not a reasonably expected outcome of a health-related procedure; or
- whilst in or temporarily absent from a mental health facility.
If the Coroner decides to investigate, a police officer assists in collecting information about the death. Usually an autopsy will be performed if an inquest is likely to be held.
In New South Wales, a deceased’s family no longer has the right to request the Coroner conduct an inquest. However, any person may seek an order from the Supreme Court requiring the Coroner to conduct an inquest.
Do I need legal representation at an inquest?
The family is not required to have legal representation at an inquest. The Coroner’s assistant can ask questions on their behalf.
However, in cases involving appropriateness of medical treatment, issues are very complex and technical. Other parties at the inquest, especially doctors and hospitals, will be legally represented. In such cases, it is worthwhile for the family to have their own legal representation.
Can the Coroner award compensation?
No, the Coroner cannot award compensation.
However, an inquest may determine that there is sufficient evidence to justify a compensation claim.
Where a death results from negligence, dependant family members may make a claim for financial support. In some cases compensation can be claimed for emotional injury, or nervous shock, suffered by survivors. It may also be possible to recover funeral costs and other expenses relating to the death.
How can we help?
Our team of highly experienced health lawyers can assist you in:
- making an application to the Supreme Court seeking orders requiring the Coroner to conduct an inquest
- liaising with the Coroner’s office
- determining questions to raise at inquest
- arranging expert evidence
- arranging an appropriately experienced advocate to represent you at the inquest.
If evidence indicates a compensation claim is worthwhile, we can assist you with this once the inquest is concluded.
We are well known and highly respected in the health and medical litigation arena, with specialist knowledge accumulated over twenty years.
She has conducted numerous inquests, many of which raised important public interest.
A couple of high profile inquests in which the Coroner made findings which suggested the actions of the health care professionals involved may support a compensation claim for the family of the deceased are the cases of Vanessa Anderson and Rebecca Murray, both of which are summarised below.
Inquest into the death of Vanessa Anderson
Vanessa was a sixteen year old girl who was struck in the head by a golf ball whilst playing in a golf tournament. She was conscious but disorientated when attended by ambulance officers on the course and was conveyed to Hornsby Hospital where a CT scan was performed and Vanessa was diagnosed as suffering a depressed fracture of her skull behind her right ear. Vanessa was then transferred to Royal North Shore Hospital (RNSH) where she died two days later despite the fact that her head injury had been classified as mild. The inquest focused primarily on the diagnosis and treatment of Vanessa during her stay at RNSH.
The Coroner reviewed the autopsy report, heard oral evidence from the health care professionals involved, the family and seven experts who were retained to provide their opinion. The Coroner found that Vanessa’s head injury was mild and not life threatening and that she died as a result of respiratory arrest due to the depressant effects of opiate medication.
The Coroner commented:
“ Vanessa’s case should be used as a precedent to highlight how individual errors of judgment, failure to communicate, failure to record accurately and poor management of staff resources, cumulatively led to the worst possible outcome for Vanessa and her family. As a Deputy State Coroner for the past 6 years I have regrettably presided over many inquests involving deaths in hospitals. In many of those cases one error or omission, sometimes a serious one led to death, however, I have never seen a case such as Vanessa’s in which almost every conceivable error or omission was detected and those errors continued to build one on top of the other.”
Factors that the Coroner found were influential in Vanessa’s death included:
- communication failures between staff;
- staff shortages;
- over-burdened staff;
- inexperienced staff;
- failure to follow medication orders;
- failure to conduct neurological examinations at appropriate timeframes; and
- failure to keep accurate medical records.
Inquest into the death of Rebecca Murray
Rebecca Murray, a 29 year old mother of two, was delivered of her third child by caesarean section at Bathurst Base Hospital. At the time of the operation, a small tear of the uterus was noticed and repaired. Rebecca was noted to have significant blood loss at the time of surgery, however, she was not administered packed cells until approximately one hour after the operation and after it had been noted that she was suffering further significant blood loss. A syntocinon drip was prescribed to assist in contracting the uterus, this was ceased when Rebecca’s condition deteriorated in the recovery room and the infusion site was needed to infuse fluids. It was recommenced approximately 40 minutes later. Rebecca was subsequently transferred back to the operating theatre where she underwent hysterectomy. She suffered a cardiac arrest on the operating table, was resuscitated and transferred to Nepean Hospital.
Rebecca died of multisystem organ failure following postpartum haemorrhage. The cause of the postpartum haemorrhage was a failure of the uterus to contract effectively.
The Coroner found that Rebecca’s death was preventable. He found that the two primary factors contributing to Rebecca’s death were:
- failure to take a full blood count (FBC), group and hold and / or cross-match prior to the emergency caesarean section. Had that been done, Rebecca would have received blood transfusions earlier and her death would have been prevented; and
- the care and treatment Rebecca received in the recovery room was inappropriate in that the staff were inexperienced in identifying a postpartum haemorrhage or understanding the significance of fundal height.
The Coroner refrained from making direct criticisms of individual medical and nursing staff, rather commenting that he saw the problems as systemic. He stated:
“The one feature that in my view stands out in the tragic death of Rebecca Murray is a failure of the health professionals who treated Mrs Murray . . . to apply a holistic approach to her overall care and treatment. There appeared too greater a willingness between various disciplines to compartmentalise their perceived area of responsibility . . . Mrs Murray appears to have fallen into a gap between the various medical and nursing roles with those involved failing to identify their individual or collective responsibility to the primary task of providing appropriate care and treatment from admission to discharge.”
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