Hospital deaths not decreasing: new study

Wednesday, 22 December 2004

The number of fatal accidents in South Australia's hospitals is not decreasing despite greater knowledge of how they occur, according to new research at the University of Adelaide.

The findings are contained in a thesis written by PhD graduate Dr Carol Grech in the University of Adelaide's Department of Public Health.

Dr Grech, who received her doctorate at the University in last week's graduation ceremonies, investigated Coronial Inquiries into "fatal adverse events" in South Australian hospitals, and the outcomes of the Coroner's recommendations.

Dr Grech found that many solutions have been proposed over the years to reduce the incidence of fatal errors in South Australia's hospitals, to little effect.

"The Coroner regularly and repeatedly identifies the same factors underlying fatal adverse events," she says.

"Despite this knowledge, and the fact that many adverse events are predictable and preventable, there is little evidence that the incidence of medical fatalities is appreciably declining.

"If government and health bureaucrats are serious about preventing fatal adverse events, then significant attention needs to be given to implementing recommendations handed down by the Coroner."

Dr Grech says immediate actions to be taken should include:

· overcoming obstacles that impede hospital deaths being reported to the Coroner;
· increasing funding to the Coroner's office to speed up investigations;
· improving the communication of Coronial findings to clinicians (the group most likely to benefit from this form of education); and
· lifting barriers (as outlined in Dr Grech's PhD thesis) that currently impede change towards best practice.

"Consumers of health care services, as well as those who work in the health system, are deserving of a safer hospital system," Dr Grech says.

"Recommendations arising from impartial, transparent and objective inquiries into hospital-related fatalities have the potential to improve public health by ensuring a safer healthcare system," she says.

"This is conditional, of course, on intended recipients of such recommendations actively learning from the findings and translating this knowledge into policies that are embedded into clinical practice."

If this does not occur, Dr Grech says, the government should either amend the Coroner's Act or consider abolishing the office.

The aim of Dr Grech's research was to establish whether the Coroner's findings have contributed to quality improvement in hospitals.

"In Australia, it has been suggested that up to 5000 deaths per year could be attributed to unintended injury, errors, complications and drug reactions related to the medical management of patients," Dr Grech says.

Social attitudes towards death have changed significantly over the last century, she says, due to improved public health and medical advances that prolong life.

"In general, the public expect to live a long and healthy life and, if they become ill, they expect a straightforward and uncomplicated hospitalisation," she says.

"When errors and mishaps occur they are viewed as unacceptable."

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