Reportable deaths and death reporting review

The Department of Health is committed to ensuring that every Tasmanian receives the best possible healthcare within a safe and supportive environment.

This commitment extends to all areas of healthcare and includes responsibilities to those individuals who die when in our care and to the bereaved, including family members and friends of the deceased. 

If we do not meet these standards, we must act to identify where we have failed and what we need to do to improve.

On 20 February 2024 the Department of Health initiated a review into reportable deaths and death reporting practices within Tasmanian Hospitals following allegations of misconduct. 

As a result, an independent clinical expert panel was appointed to investigate. 

The Panel

The Panel was led by Adjunct Professor Debora Picone, who brought a wealth of experience from her previous role as CEO of the Australian Commission on Safety and Quality in Health Care. 

Prof Picone has valuable knowledge of the Tasmanian health system having most recently chaired the Major Hospital Emergency Department Review to Improve Patient Access and Flow as well as co-chairing the LGH Governance Advisory Panel in response to the Tasmanian Commission of Inquiry into Child Sexual Abuse in Tasmanian Institutions.

The other members of the panel included: 

• Adjunct Professor Karen Crawshaw PSM who has held several senior executive positions within the NSW Public Service including as NSW Health’s Director Legal and General Counsel and Deputy Secretary Governance with Workforce and Corporate. Prof Crawshaw also co-chaired the LGH Governance Advisory Panel with Prof Picone.
• Adjunct Professor Amanda Walker, who comes with extensive experience as a Specialist in Palliative Medicine and Clinical Safety Advisor. Prof Walker has also worked at the NSW Clinical Excellence Commission and as a Clinical Director for area health.
• Ann Maree Keenan, RN GAICD, who is a highly respected health leader who has led healthcare reforms, workforce development changes, quality and safety reviews and statewide improvement initiatives.

The Panel was supported by Dr Dinesh Arya, Chief Medical Officer (CMO) and Chief Psychiatrist for Tasmania and a member of the Department of Health Reference Group. Dr Arya has over 20 years’ experience in senior health executive roles both within Australia and overseas, and was most recently the CMO and Chief Psychiatrist for the ACT.

A Reference Group made up of leaders with relevant expertise from across the Department, including Hospitals and Primary Care, Statewide Quality and Patient Safety Service, Clinical Quality, Regulation and Accreditation (CQRA), Risk and Legal Services was established to support the Review. 

Focus area

The focus of the Panel was to:

• review any identified patient deaths to determine if these cases are reportable deaths
• make recommendations if cases require follow up actions, including open disclosure with next-of-kin, disciplinary action or reporting to regulatory or other agencies
• review all public hospital death reporting procedures to ensure procedures meet all relevant legal and clinical reporting standards and have appropriate escalation protocols to allow clinicians at any level to request an internal review of a decision relating to a death within a hospital.

View the Terms of Reference for Reportable Deaths and Death Reporting Processes in Tasmanian Public Hospitals.

Review Methodology 

The Review was multi-faceted and involved: 

• Meetings with Staff Members: Engaging with system administrators, quality patient safety advisors, executive directors of medical services, and medical consultants; 
• Meetings with Family Members and Staff: Addressing concerns raised about the death certification process; 
• Policy and Document Review: Undertaking a comprehensive review of departmental policies, protocols, and death reporting documents; 
• Interviews with Departmental Employees: Collecting formal information and personal accounts from current and former employees; and 
• Review of Clinical Cases: Detailed examination of numerous clinical cases to assess patient care and death circumstances.

Final report

The Final Report of the Independent Review into Reportable Deaths and Death Reporting Processes in Tasmanian Public Hospitals was published on 28 June 2024. 

View the Final Report if the Independent Review into Reportable Deaths and Death Reporting Processes in Tasmanian Public Hospitals.

Conclusions

• The Review identified significant issues in death reporting practices, particularly concerning the actions of the former staff member. 
• The Panel has recommended a total of 29 deaths be reported to the Coroners' office: in addition to this, 28 inaccurately attested MCCDs are recommended for referral to relevant authorities and/or the Registrar of BDM. 
• The Panel has found that the former staff member has engaged in a repeated pattern of acting outside the scope of Section 35 of the Registration of Births, Deaths, and Marriages Act 1999, and has repeatedly inaccurately represented their standing to certify MCCDs in the relevant attestation on those MCCDs. The Panel considers this a serious and sustained departure from the expected standards of knowledge, skill, and judgement for an experienced medical administrator.
• The Panel has therefore recommended the former staff member be reported to the Medical Board of Australia. This is on the basis that there is a consistent pattern of cases in which they have certified deaths which prima facie they were not qualified to certify, and incorrectly attested as a medical practitioner who attended the patient in their last illness. This pattern of conduct raises the issue of unsatisfactory professional conduct and whether they are a fit and proper person. 
• The Review also identified several cases where, in the Panel's opinion, deaths should have been reported to the Coroner. In some instances, this non-reporting appears to have followed discussions with the Coroner's office at associate level. However, there is a lack of contemporaneous medical records in respect of these interactions between the former staff member and the Coroner's Office. As a result, the Panel is unable to ascertain what the reasons were for the cases appearing to be “returned” to the THS for death certification. 
• Accordingly, the Panel has recommended that those cases, which, on review of the relevant documentation the Panel considered should have been reported to the Coroner, rather than certified by a doctor within the THS, now be referred to the Coroner. 
  • The Panel wishes to emphasise that referral to the Coroner is being made in the interests of transparency and independent scrutiny. 
  • No inference should automatically be drawn that there is something suspicious or otherwise untoward about the deaths in question or the causes of death cited on the MCCDs.
• The management of deaths administration and certification is a serious matter, carefully regulated through a comprehensive legislative regime. It is also an important duty from a medical professional perspective, and the deceased and their families are entitled to have processes and practices carried out with due skill, care, professionalism. Whilst THS does have comprehensive policies and electronic systems to support appropriate management of death reporting and certification, there are aspects that should be made clearer. Work is already underway to ensure these improvements are made. 
• Recommendations have also been made to improve policies, protocols, and training to ensure accurate death certification and compliance with statutory requirements. The Panel commends ongoing efforts by the THS and the DoH to address these issues and enhance the safety and quality of patient care.

Next steps

This is a highly sensitive subject and our first priority as a Department has been to liaise with the families affected and to provide the ongoing support and information they require throughout this process.

The Department will also refer the report to the Integrity Commission and to Tasmania Police for their advice. This new information will also be added to the Department of Health’s APHRA notification relating to this issue.

The Acting Secretary of Health issued an apology to those affected and has committed to putting in place the recommendations contained within the report.

Further details will be published here in future.