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Documentation is your ‘best defence or worst enemy’ at a coronial inquest: expert


Aged care managers need to ensure they properly manage complaints, as coronial inquiries are often prompted by complaints from family members dissatisfied with a facility’s explanation for an adverse event or outcome, a health safety and risk management expert has said.

Further, managers need to ensure they have robust documentation processes in place, as documentation could be a facility’s “best defence or worst enemy” in a coronial inquiry or inquest.

Michele Moreau of the Preventing Harm Initiative told the Nurses in Management Aged Care (NIMAC) conference on Thursday that facilities should use the process of ‘open disclosure’ in which they discuss with families the steps they will take to prevent similar incidents occurring again.

Speaking on coronial inquiries and the lessons from them for aged care providers, Ms Moreau told the Queensland audience that the open disclosure approach had saved millions in litigation in the United States and often successfully prevented the need for coronial inquiries.

“Open disclosure involves an apology for what happened. It is purely about empathy not acceptance of blame… you are apologising for the experience,” said Ms Moreau, who led a trial of the model in the South Australian health sector.

The approach typically involved investigating and explaining what went wrong, what was done to handle it at the time, what was done to prevent it, and what would prevent it in the future, she said.

Ms Moreau, a former regional manager for patient safety and risk management for Southern Adelaide Health Services, said that facilities should always investigate any serious event that resulted in harm. However, she stressed that any improvement recommendations identified should be implemented; a “big risk” for a provider at a coronial inquest was when they had conducted an investigation, made recommendations, but not implemented them.

Among Ms Moreau’s key advice to aged care managers was:

  1. Documentation matters – it is your best defence or your worst enemy. In particular, beware where risks are identified and not managed; there is no evidence of care plan implementation; no evidence the client made an informed choice about risk; and where incidents don’t contain prevention strategies.
  2. Anticipate and manage complaints – this prevents litigation and coronial inquiries.
  3. Internally investigate any unexpected deaths and identify areas for improvement.
  4. Be proactive about improving practice and don’t wait for a coroner’s recommendation.
  5. Ensure improvements are evidence based.
  6. Don’t claim to have implemented improvements or recommendations unless you have.

For managers or staff called to give evidence at a coronial inquest, Ms Moreau advised they read from their progress notes, detailing what they heard, saw, did and communicated, and not what they thought or assumed at the time.

When present in the coroner’s court, she advised the staff show empathy and emotion for the situation. “Do not discuss the case openly in the court or surroundings as the family might be around… Limit the number of staff attending,” she advised.

Australian Ageing Agenda is the NIMAC conference media partner. 

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