To the Editor: Van Der Weyden highlights the need for a health system with a focus on patient safety that is open, transparent and connected to local communities and clinicians who are able to make decisions about health care delivery.1 The editorial refers to the Bundaberg and other Australian hospital “scandals” that went undetected by medical boards, the clinical governance structures within each hospital, and sentinel event reporting processes. However, no consideration is given to the role of the Coroner’s Office, where a formal structure is already in place for reviewing particular deaths associated with health system failures.

The role of the Coroner’s Office in these incidents is worth reflecting on, as the Coroner is external to the health system, has the capacity to review reported hospital deaths, and can address the concerns of doctors and nurses as well as the family members of the deceased. The case involving Dr Patel begs the question of whether this system of judicial investigation was utilised. If not, how could the system improve to encourage the disclosure of internal problems in our hospitals?

One option to improve the system has been developed by the Clinical Liaison Service. This service was initiated by the State Coroner’s Office in Victoria to involve clinicians in a regular review of deaths in hospital as a means of identifying potential instances of hospital system failures.2 Through a system-based approach, issues of communication failure, unclear work protocols and a lack of supervision for junior doctors have been highlighted. These issues are fed back into the health care community through coronial findings and the service’s quarterly publication Coronial communiqué.3

Improving the clinical input into judicial investigation may, by encouraging clinicians’ trust in the system, remove barriers to identifying system issues relevant to health care. Currently, Victoria is the only state or territory in Australia where clinical input is a routine part of the Coroner’s review process. Although the Coroners’ jurisdiction only extends to instances resulting in death, their findings are often far-reaching and garner public attention and support.4

Another initiative to improve this system is the development of the National Coroners Information System (http://www.vifp.monash.edu.au/ncis/). This database provides a national repository of information about reported deaths, and has the potential to be used as a health and injury surveillance system to inform policy for death prevention.

As noted by Morton, system analysis requires a process that is just and transparent.5 The coronial process inherently comprises both of these features through its legislative structure. It is conceivable that a team of clinical reviewers within the Queensland Coroner’s Office could have identified issues at Bundaberg earlier on.

Our health system unquestionably requires a better strategy for preventing the patient deaths that occur every day. The Clinical Liaison Service and the National Coroners Information System are helping the legal and health care community to work towards identifying and preventing incidents that compromise patient safety.