Reportable deaths and death reporting review
The Department of Health is committed to ensuring that every Tasmanian receives the best possible healthcare within a safe and supportive environment.
A recent House of Assembly Select Committee Inquiry into the Transfer of Care Delays heard serious allegations relating to reportable deaths to the Coroner.
As a result, an independent clinical expert panel has been appointed to determine if identified cases are reportable deaths. This is in addition to a broader review of the processes around reporting deaths to the Coroner.
The Panel
The Panel is being led by Adjunct Professor Debora Picone, who brings a wealth of experience from her previous role as CEO of the Australian Commission on Safety and Quality in Health Care. Prof Picone has valuable knowledge of the Tasmanian health system having most recently chaired the Major Hospital Emergency Department Review to Improve Patient Access and Flow, as well as co-chairing the LGH Governance Advisory Panel in response to the Tasmanian Commission of Inquiry into Child Sexual Abuse in Tasmanian Institutions.
Prof Picone will also be joined on the panel by:
- Adjunct Professor Karen Crawshaw PSM who has held several senior executive positions within the NSW Public Service including as NSW Health’s Director Legal and General Counsel and Deputy Secretary Governance with Workforce and Corporate. Prof Crawshaw also co-chaired the LGH Governance Advisory Panel with Prof Picone.
- Adjunct Professor Amanda Walker, who comes with extensive experience as a Specialist in Palliative Medicine and Clinical Safety Advisor. Prof Walker has also worked at the NSW Clinical Excellence Commission and as a Clinical Director for area health.
- Ann Maree Keenan, RN GAICD, who is a highly respected health leader who has led healthcare reforms, workforce development changes, quality and safety reviews and statewide improvement initiatives.
The Panel is being supported by Dr Dinesh Arya, who is the recently appointed Chief Medical Officer (CMO) and Chief Psychiatrist for Tasmania and a member of the Department of Health Reference Group. Dr Arya bring with him over 20 years’ experience in senior health executive roles both within Australia and overseas, and was most recently the CMO and Chief Psychiatrist for the ACT.
A Reference Group made up of leaders with relevant expertise from across the Department, including Hospitals and Primary Care, Statewide Quality and Patient Safety Service, Clinical Quality, Regulation and Accreditation (CQRA), Risk and Legal Services will also be established to support the Review.
Focus area
The Panel will:
- review any identified patient deaths to determine if these cases are reportable deaths
- make recommendations if cases require follow up actions, including open disclosure with next-of-kin, disciplinary action or reporting to regulatory or other agencies
- review all public hospital death reporting procedures to ensure procedures meet all relevant legal and clinical reporting standards and have appropriate escalation protocols to allow clinicians at any level to request an internal review of a decision relating to a death within a hospital.
Next steps
The Independent Panel is expected to report its findings and recommendations to the Secretary, Department of Health by 30 April 2024.