Every jurisdiction in Australia has legislation that establishes the role and function of the Coroner and the Coroner’s court.
Of particular relevance to healthcare professionals is the power of the Coroner to conduct an Inquest into a reportable death which is defined in each jurisdiction and includes deaths that are unexpected, unnatural, as a result of violence or unknown causes.
In some jurisdictions more specific criteria include deaths within 24 hours of a surgical, some medical procedures or discharge from hospital or whilst the person is in custody or care.
The primary purpose of a Coronial Inquiry is to identify the person, the circumstances, cause and manner of their death (Coroner’s Act 2003 (Qld)). However, the Coroner’s office also has a broader role in prevention which is achieved through making recommendations aimed at reducing or preventing a recurrence of a similar event that was the subject of the Inquest.
This is achieved by identifying shortcomings or failures of individuals or organisations in connection with a person’s death rather than assigning blame or fault, in order to ensure lessons are learnt from mistakes in the hope that this will improve public health and safety in the future (The Inquest into the death of Ahlia Raftery (2017) NSW).
That said a Coroner will not hesitate to identify systemfailures and name poor conduct and practice where evidence suggests these contributed to the death of a patient. Such comments create opportunities to reflect upon practice and workplace systems and perhaps question long standing practices. One important area of practice that frequently attracts the attention of the Coroner is record keeping. Documentation in patients’ case notes whether in paper or electronic form continues to be a major concern and feature in Coronial Inquiries.
From risks associated with exception based record keeping, to the impact of a failure to document and false documentation, comments from cases such as Coronial Inquests help to provide organisations and practitioners with a framework of what is good documentation and what you should avoid when writing in the patient’s notes.
Coronial comments are not confined to content. There are many styles or forms of record keeping and which style is used is a matter of organisational discretion based in part on the service they provide.
Organisations involved in the long term care of clients commonly rely on ‘exception based’ record keeping. In this style of record keeping comment is made in the client’s record when something exceptional or out of the ordinary occurs.
A Coroner has recently highlighted the potential risk in this approach – determining what is exceptional.
In that case the residential care facility was managing a resident’s (who assaulted the deceased) ongoing physical and verbal aggression. The Coroner raised the point that in cases such as this when the behaviour is not uncommon and records of episodes of aggression are only recorded when ‘out of the ordinary’ it is possible that not all episodes will be recorded as the behaviour becomes normalised (Non – Inquest into the death of Betty Quayle 2019). As such what becomes ‘exceptional’ and who determines this?
The value of the Coroner’s comments and findings lies in the point that there are few specific legal guidelines on what is good documentation despite this being an area of practice that clinicians are often looking for clear direction in. What you actually write in the patient’s record is up to a point a matter of professional judgement – what you determine is important information to include in the contemporaneous account of patient care delivery.
There is a list of points that help guide basic documentation. These are to ensure that your documentation is:
- Edited – checking for ambiguity and spelling mistakes
- Absent of unapproved abbreviations
Unfortunately, the failure to follow these simple and basic guidelines has the potential to have an adverse effect on good patient care outcomes.
Examples from courts and tribunals as to what has been identified as flaws in documentation and how these can be used to improve record keeping will be explored in the next edition of this journal.
Coroners Act 2003 (Qld)
Inquest into the death of Ahlia Raftery (2017) NSW
Non-Inquest findings into the Death of Betty Quayle (2019) Qld
An expert in the field of nursing and the law Associate Professor Linda Starr is in the School of Nursing and Midwifery at Flinders University in South Australia
It needs to be realised “who” actually writes the documentation. (The level of training/expertise)
If there are e.g, 59 residents in an Aged Care Facility, the amount of time this takes is subtracted from the time staff are available to “care” 1:1.
Whilst documenting, that amount of time is not being spent with residents.