Published: 19 March 2015

[12.47 p.m.]

Ms FORREST (Murchison) - Mr President, I support this bill.  There are a number of ways it tidies up many areas that have been a bit confusing at times, particularly that of deaths related to medical treatment.  It has always been a very difficult time for families and health professionals when a death occurs in a hospital, particularly when it is not expected. 


There have often been grey areas about whether it should be a coroner's case or not, when should the coroner be notified and those sorts of things.  It adds to the stress and grief of people.  It is not just the family members who experience the grief, it is the health care providers as well.  It has been an area of confusion at times, and this helps to clarify many of those issues.


It is fair to say there are very few cases, for example, of a surgeon taking a patient to theatre for a procedure, expecting them to die.  Generally you do not, otherwise you would not bother to take them to theatre.  I recall one instance where that was the case.  The patient was pretty much deceased but she was taken to theatre on the odd chance the operation could save her life, following a birth.  You do everything you can in circumstances like that.  You do not expect women to die in childbirth in our country, but occasionally they do.  There are circumstances sometimes where you may well be expecting the person not to survive but you do what you can anyway.  Naturally, that case would already be considered a coroner's case because the circumstances that led to her being in that situation would warrant such an investigation and an inquest.


When I was looking through this bill and the second reading speech, when the Leader said the definition of the term 'inquest' will be amended and expressed in similar terms to the Victorian Coroners Act 2008 to mean 'a public inquiry that is held by the Magistrates Court (Coronial Division) in respect of a death, a fire or an explosion', I was wondering, are there other circumstances that are excluded in that?  One that comes to mind is a bomb blast where people are killed.  Is there a separate process around that?  A bomb blast would often cause a fire and certainly an explosion.  But is an explosion included in that?


It seems that once we start to narrow things and specifically identify circumstances, we run the risk of excluding others.  Is it meant to be a limiting provision, or is it meant to encompass deaths that occur from unexpected circumstances, even things like car crashes?  It is not a huge concern, but I am interested in why it is limited, if in fact it is, to those sort of things.


Going back to the coroner's power to hold an inquest.  The bill would amend the Coroners Act to expressly confer upon the coroner a general discretionary power to hold an inquest into a reportable death.  That is eminently sensible.  If there is doubt as to whether the coroner can conduct an inquest it must be quite confusing.  That has been an issue in the case of some deaths that occurred in hospitals, where there was uncertainty about whether or not a coroner's inquest would be held.


As I understand it, and I am seeking clarification from the Leader on this, this bill does not remove or diminish in any way the right of a family member or member of the nursing staff or medical staff to request the death be referred to the Coroner.  You may have a patient who was expected to die, but perhaps not today.  In those circumstances, does a member of the family or a concerned health professional have the capacity to refer the death to the Coroner?  I want to clarify that.


Many of us have probably dealt with constituents whose loved ones have died in unexpected circumstances in hospital.  In my years of working in nursing, I often talked to family members after a death.  Sometimes they feel aggrieved if there is not been a proper inquiry into the death - even though the person may have been critically ill, or may have been expected to die at some stage - when they are concerned about mismanagement or perhaps a medication error.  I recognise that issue is being tidied up in this bill.


We recently heard of a finding at one of our major hospitals regarding a whole series of failures that resulted in the death of a patient.  They are very real issues - very distressing for the families and also the medical staff involved.  We are all human, we all make mistakes, and tragically sometimes those mistakes have very dire consequences.  We need to ensure that these things are properly investigated, because it is only when that happens, that other events can be prevented in the future.


I have assisted some of my constituents to follow up the tragic loss of life of young family members - young fathers of children and mothers of young children - who possibly would not have died if other treatment had been provided.  When those things happen - and they have been Coroner's cases, there is no question about that - the findings of the Coroner have definitely directed changes in practice in our health facilities to avoid similar incidents.


Sometimes, though, changes have not happened as a result of the Coroner's inquest.  They have happened because the family was not happy with the outcome, or the report of the Coroner.  One Coroner's report I read was terribly written - they even called the patient by the wrong name, they had his date of birth wrong in the report and many other things were wrong.  It was really distressing for the wife, who is my constituent.  I found the Coroner's report very hard to read, knowing the case.  We went through a process, through the Health Complaints Commissioner and eventually received an outcome that did help her and her family.  The biggest thing for her, as it often is with other cases I have helped with, is that there was a change of practice, a change of procedure or policy.  That means that no other family should suffer that same experience again.


There are always two sides of this but we went through a conciliation process in that case and it was really helpful for that woman to sit across the table from the doctors involved in her husband's care, and to say that they are real people too, they are all humans, and they hurt as well.  I get emotional about this case because it was a very difficult case with this friend of mine from many years ago.


I support these changes.  It will clarify many of these areas that are related to unfortunate and tragic deaths.  These are a couple of questions I have for the honourable Leader.


[12.56 p.m.]

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