"The most fundamental responsibility of any coroner is to investigate the circumstances of a reportable death to determine the cause and manner of death. The death may be investigated at an inquest and that investigation may or may not reveal contributing factors that result in recommendations being made in the interests of public health or safety.
"In determining the circumstances attending a person's death, a coroner does not apportion blame. In keeping with the ethos of patient safety, a coroner may make comments about procedural and systemic improvements that could be made to prevent recurrence.
"Coronial recommendations provide health services with an opportunity to address risks to patient safety. I encourage all health services to utilise these summaries as a means of raising awareness of important messages which have come from the investigation of the circumstances attending these deaths so that lessons learned can protect the living." Ms Ros Fogliani, WA State Coroner
Patient Safety Surveillance Unit