Quality improvement themes from coronial recommendations received
by the Chief Psychiatrist
Under the provisions of the Mental Health Act 1986, mental health services
are required to notify the Chief Psychiatrist of the death of any patient
that is a reportable death within the meaning of the Coroner’s Act 1985.
The Chief Psychiatrist registers an interest with the coroner regarding
the findings arising from any coronial inquest or inquiry into these deaths.
The Chief Psychiatrist is in a unique position to review these findings
and to identify emerging themes across the service system.
Currently, the Chief Psychiatrist publishes regular summaries of coronial
findings for the mental health sector – these summaries draw together
the key clinical practice and standards issues for a given period and
highlight areas for ongoing quality improvement action. Services are encouraged
to review their local practices, policies and procedures and implement
action plans to address the issues identified.
Quality improvement themes from coronial recommendations received by the Chief Psychiatrist in 2008 (PDF file 127KB)
Quality improvement themes from coronial
recommendations received by the Chief Psychiatrist in 2007 (PDF file 84KB)
Quality improvement themes from coronial
recommendations received by the Chief Psychiatrist in 2006 (PDF file 83KB)
Quality improvement themes from
coronial recommendations received by the Chief Psychiatrist in 2005 (PDF
file 85KB)
Quality improvement themes from coronial
recommendations received by the Chief Psychiatrist in 2004 (PDF file 51KB)
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