From Death We Learn

28 November 2019

From Death We Learn is an annual publication that has been available since 2006. It provides summaries of health-related coronial inquest findings.

High quality organisations and systems routinely utilise both internal and external processes to review and improve their services, with coronial inquests being one important external mechanism from which to learn.

Key messages for a case, or for a theme of cases, are included to raise awareness of concerns relating to the circumstances of the death and/or possible contributing factors. A series of discussion points are highlighted to encourage reflection, promote education across health services as well as to initiate quality improvement discussions.

Acknowledgements to the friends and families of loved ones whose deaths have been investigated by the Coroner. It is with the utmost respect to them that this publication is collated in the hope that it will complement the death prevention and public safety role of the Coroner, and ultimately improve the safety and quality of care delivered to patients.

Produced by

Patient Safety Surveillance Unit