The impact of a clinical team assisting the Coroner’s investigation of healthcare-related deaths: Reflections on six-years of service Academic Article uri icon


  • AIM: This study describes the short-term impacts of an on-site team of practising clinicians (Clinical Liaison Service, CLS), in enhancing the Coroner's investigation for the prevention of healthcare-related deaths. METHODS: An internal observational program evaluation was conducted where objective and externally verifiable achievements of CLS over a six-year period were provided in relation to definable program components. RESULTS: From 2003-2008, the same conceptual model for CLS was in place. CLS developed and implemented for the death investigation process: (i) a working model for a comprehensive and standardised clinical review; (ii) a knowledge management strategy to enhance the healthcare sector access to information and coronial (iii) activities to improve communication channels between the Coroner's Office and the healthcare sector. The short-term impact included improved appropriateness of cases that proceed to investigation; improvements in the nature and depth of the investigation, and self-reported changes to clinicians practice. CLS reflected that the clinically enhanced investigation improved the credibility of the Coroner's death investigation, reduced apprehension in the healthcare sector about the purpose of the investigation and engendered co-operation between involved parties. DISCUSSION: This study suggests that a team of practising clinicians assisting the Coroner's investigation of healthcare-related deaths contributes towards improving patient safety.


  • Ibrahim, Joseph E
  • Cunningham, Nicola Y
  • O’Brien, Adam J
  • Charles, Amanda J
  • Young, Carmel MF

publication date

  • January 2010