How to survive a coroner's court: A clinician's guide.

Abstract ObjectivesTo present the epidemiology of suicidal charcoal burning in Hong Kong and long‐term outcomes for survivors presenting to the Accident and Emergency Department.MethodCases of suicidal charcoal burning were retrieved from databases of the Coroner's Court and Hong Kong Poison Information Centre. Pertinent demographic and clinical data were retrieved and analysed with R version 4.1.0, where statistical significance was defined as p < 0.05. Backward stepwise logistic regression was performed on gender (male), age (older than 50 years), coingestion, month (October to April) and day (weekend) to identify any outcome predictors. The post‐charcoal‐burning 9‐year medical record of the cases transferred to the hospital after charcoal burning was retrieved from the electronic patient record of the Hospital Authority and analysed.ResultsThere were 429 cases of suicidal charcoal burning in Hong Kong from 1‐1‐2014 to 31‐12‐2015. The overall prehospital and in‐hospital case fatality rate was 59.4%. Gender (male), age (older than 50 years), coingestion and day (weekend) were identified to be predictors of fatality. Over half of the cases presented to the Accident and Emergency Department had no or a minor effect.ConclusionThe epidemiology of suicidal charcoal burning in Hong Kong and long‐term outcomes for survivors were presented. Gender (male), age (older than 50 years), coingestion and day (weekend) were identified to be predictors of fatality. Selected cases of suicidal charcoal burning, especially those with no or minor effects, can be safely managed by the Accident and Emergency Department, avoiding unnecessary admission to the medical ward.

This article considers the role of coroners as a porthole into the content and operation of voluntary assisted dying (VAD) regimes. In their role as investigators of unexplained, unnatural, violent and accidental deaths, coroners are uniquely positioned by legislation to identify abuses and anomalies in VAD deaths. They also have an informed perspective enabling them to identify issues and patterns of deaths among persons who cannot avail themselves of VAD because of how eligibility criteria have been framed. Coroners have an ability too to chronicle the human toll of such ineligibility for persons determined not to satisfy qualifying requirements for access to VAD. This article reviews an important set of findings and comments by the Victorian Coroners Court late in 2024 which addressed the issues and identified other such findings in an attempt to assist reform processes for VAD legislation to be informed by coronial experience. It also notes safety issues highlighted by a strongly worded 2024 decision by the Queensland Coroners Court which is likely also to prompt discussion about VAD processes and the need for controls over unintended access to VAD and other euthanasia medications.

Despite our existing knowledge about fall prevention, older adults are still falling, and some die from those falls. Much of this knowledge comes from work done with live patients. Coroners (who investigate sudden and unexpected deaths) offer fresh insights into preventive lessons for minimising falls in older adults. Coroners have a legal public health function to reduce preventable deaths. Their court investigations draw from documents, such as witness statements, police records, healthcare records and expert witness statements. The lessons gleaned from the rich coronial data could be incorporated into updated versions of the World Fall Guidelines. Despite the preventive power of coronial data, it is an under-researched and under-used source of prophylactic insights for fall prevention. Numerous preventive lessons have emerged from our ongoing study of Australian coroners' cases about fatal falls in older adults living in residential care. Specifically, these prophylactic learnings involve equipment, legal and policy changes and systems-level adaptations. While recognising the robustness of the World Falls Guideline, the coronial examples studied were not described in the working group specific to them and could add value to preventing falls in aged-care facilities. The global interest in the ageing population calls for serious consideration of additional ways to glean fall prevention insights. It is time to recognise and harness the preventive power of coronial data to benefit older adults and our communities.

Trends in Sudden Unexpected Deaths in an Australian Population: Impact of the COVID-19 Pandemic

Abstract Purpose This study examined factors present among older adult family homicide victims and their offenders compared to younger adult family homicide using the social-ecological model. Method The study used a population-based single-jurisdiction cross-sectional design of consecutive homicide cases of adults (aged 18 years and older) reported to the coroner in Victoria, Australia for the period 2001–2015. Included were homicides involving an intimate or familial relationship. The data source was the Victorian Homicide Register, maintained by the Coroners Court of Victoria. Descriptive and multivariate analysis was performed to compare the presence of factors between younger and older adult family homicides. Results During the study period 37/283 (13.1%) family homicides occurred among older adult victims (aged 65 years and older) and 246/283 (86.9%) occurred among younger adults (aged 18–64 years). The deceased older adult was often male (57%), with a documented physical illness (54%). Offenders against the older adult were frequently male (68%), non-intimately related (73%), with diagnosed mental illness, a history of substance use and/or historical exposure to violence (all 57%). There were 15 older adult family violence (FV) homicide victims, eight that were previously victims of the homicide offender, primarily enduring emotional, physical and psychological violence as well as the perpetrator assaulting another family member. Seven older adults had perpetrated FV against their offender. Conclusions The history of violence perpetration in the deceased and mental health factors in their offender, as well as the greater proportion of parent-child and other familial relationships offer interesting focal points for future prevention research.

AimsNavigating a Serious Incident (SI) investigation and participating in a Coroner's Court proceedings can pose challenges for psychiatry trainees. The Higher Training curriculum emphasizes active participation in activities that enhance patient safety and care quality. This project aims to enhance patient safety and trainee confidence by improving training on SI investigations and Coroners Court proceedings.MethodsUsing Quality Improvement (QI) methodology, in the first cycle an initial survey was distributed to all psychiatry trainees and middle grade doctors working in Kent and Medway (n = 67) to establish baseline knowledge and confidence levels in areas related to risk assessment & management, SI investigations and Coroner's Inquests.In response to the identified need for training, we organized the Initial Training Event with support from Deputy Chief Medical Officer for Quality and Safety, Patient Safety Team and Medical Education Department. The half-day, in-person event was opened to all doctors and featured 5 sessions: Serious Incident Investigation Process, Thematic Review of Suicides, Systems Engineering and Human Factors in Patient Safety, Learning from Mortality and Structured Judgement Review along with ‘Being Involved in Investigation – An Investigator's Guide’. Data from a survey of attendees (n = 47) informed the development of a tailored training session for psychiatry Core and Higher Trainees.ResultsThe initial survey received 32 responses (response rate: 47.76%). 71.88% of respondents had little to no understanding of SI investigation processes. Remarkably, 87.5% expressed strong interest in receiving training on conducting SI investigations. 90.62% were extremely or very interested in receiving training on participating in a Coroner's Inquest.47 doctors attended the Initial Training Event. 30 responded to the feedback questionnaire (47.76%). All doctors found the training useful, with over 90% rating it ‘very’ or ‘extremely’ useful. 97% felt that the training would improve their clinical practice in terms of patients’ safety. After the training, 60% understood the process of conducting an SI investigation a moderate amount; 33.33% understood the process a lot or to a great extent. Nevertheless 92.86% felt a need for additional training in SI investigations. 63.33% suggested making training available yearly, and 36.67% favoured making it mandatory training.ConclusionThis project identified a significant need for training in SI investigations and Coroner's Court proceedings among psychiatric trainees. An Initial Training Event developed from the first QI cycle survey data received positive feedback. The next phase involves developing a tailored training program that addresses identified knowledge gaps. Further considerations include making this training a regular event.

The term ‘vicarious trauma’ refers to a range of cumulative and harmful effects from exposure to the trauma of others and is now recognised as a category of causation in the diagnostic criteria of post-traumatic stress disorder. Legal practitioners may be exposed to the risk of harm from vicarious trauma in a number of occupational contexts. This article reviews recent case authority, including a 2023 prosecution of Court Services Victoria for failing to provide a safe workplace in the Coroners Court of Victoria and the High Court decision in Kozarov v Victoria (2022) and the Victoria Court of Appeal decision in Bersee v Victoria (2022). It considers measures that should be taken to provide a workplace for both legal practitioners and judicial officers that is as safe and without risks to health as is reasonably practicable.

SummaryBackgroundGambling is associated with serious harms to health, including suicide. Yet public health systems for recording the role of gambling in suicide deaths are relatively underdeveloped. This study contributes to the understanding of this relationship.MethodsA population-based cross-sectional study of suicides reported to the Coroners Court of Victoria between 2009 and 2016 was performed to identify the incidence and characteristics of gambling-related suicides (GRS).FindingsFrom 2009 to 2016 there were 4788 suicide deaths in Victoria. Of these, 184 were identified as direct GRS and a further 17 were GRS by ‘affected others’. Together, these GRS comprise 4.2% of all suicides in Victoria over this eight-year period. Direct GRS account for an annual average rate of 5.13 GRS per million Victorian adults. GRS were significantly more likely to be male (n = 153, 83%), than the Victorian population of total suicide deaths and significantly more likely to occur among those most disadvantaged. Family members and friends were more likely than clinicians to know about the deceased gambling.InterpretationGiven that gambling is not routinely investigated by coroners and may be hidden from family, friends, and health professionals, this is an underestimate of the true scale of the GRS in Victoria. A range of measures should be introduced to prevent, screen, support, and treat gambling harm. Family members and friends should also be provided with help services. Preventing gambling-related harm through public health measures could significantly reduce suicidality and suicide, both in Australia and globally.FundingFederation University Australia, Coroners Court of Victoria, Suicide Prevention Australia.

Availability and quality of data related to cultural and linguistic diversity in the Victorian Suicide Register: A pilot study

AimsSeveral studies on simulation as a method of teaching have identified advantages- on attitudes, skills, knowledge and behaviours, and non-technical skills such as situational awareness, team working, interpersonal interactions with improved confidence. Use of simulation in Psychiatry is growing, but studies are limited. We decided to evaluate our own delivery of simulation in trust and align this to the national strategy to identify gaps and further workMethodsWhat are we offering now?Core trainees- Emergencies in Psychiatry- seclusion, suicide risk assessment and fracture neck of femur. Communication skills course, mock CASC, ILS.Higher trainees- Tribunal preparation and providing evidence, Induction- Out of hours supervising 1st on call, Managing serious incidentIn development-Immersive technology- Higher trainee supervising a junior doctor OOHResultsChallenges and solutionsParticipant anxiety-Performing in front of peers can be demanding and reduces take up. ‘What to expect’ pre-session workbook, small group numbers (3), reiterating the focus of session on learning and confidentiality has improved participation.Resource (scenario development) - Takes time and effort to achieve high quality, piloting and continual adjustments to tailor to the learners' needs. We appointed 3 SIM leads and hold regular meetings.Resource (trainers)- Hard to resource trained trainers. Developed an in-house training programmes for trainers, but persistent difficulties in maintaining consistency and time commitments with same group of ‘trained trainers’. Included brief training pre-session in morning for facilitators.Resources (finance)-Expensive to support Simulated patients. We used COVID-19 recovery funds and constructed purpose-built SIM rooms in education centre, which adds to fidelityConclusionFeedback: Excellent feedback received with positive comments about supportive learning, SIM facilities and debriefing.Despite being highly resource intensive, simulation is a powerful, unique, and valuable method of training in Psychiatry. Availability of resource will continue to pose challenges, but use of digital Immersive technology and focussing on relevant areas in line with National vision strategy and with identified groups- Induction, SuppoRTT, new to NHS, Remediation, CASC preparation and enhancing capacity of learning environment where there are gaps may be a good starting point. Use of MDT integrated scenarios can offer more fidelity.Future identified areas will beCT1s-Physical health skills (refresher), history taking, MSE, handover. Emergency scenarios- NMS, lithium toxicity, cardiac complications due to clozapineHigher trainees- Mental health act assessments, supervising doctors in training/members of MDT. Chairing team meeting, handover, breaking bad news, presenting in a coroner's court

Spatial–temporal analysis of suicide clusters for suicide prevention in Hong Kong: a territory-wide study using 2014–2018 Hong Kong Coroner's Court reports

A network approach to understand co-occurrence and relative importance of different reasons for suicide: a territory-wide study using 2002–2019 Hong Kong Coroner's Court reports

Reviewed by: Execution Culture in Nineteenth Century Britain: From Public Spectacle to Hidden Ritual ed. by Patrick Low, Helen Rutherford, and Clare Sandford-Couch Michael Meranze (bio) Execution Culture in Nineteenth Century Britain: From Public Spectacle to Hidden Ritual, edited by Patrick Low, Helen Rutherford, and Clare Sandford-Couch; pp. xv + 199. London and New York: Routledge, 2021, $160.00, $48.95 paper, $44.05 ebook. The Capital Punishment Amendment Act of 1868 cut a caesura into the history of Britain's penal practices. For centuries hangings had been consistent features of Britain's public space, with the Law's ultimate display designed to clarify before the eyes of the public the penalties that accrued to those who violated its most serious mandates. After the Act, that display would be moved within walls, separated from the crowd that had traditionally been its immediate audience. Although hangings would continue, a new, more intense process of mediation would replace the visceral and visual sight of the body broken on the gallows. Execution Culture in Nineteenth Century Britain: From Public Spectacle to Hidden Ritual, edited by Patrick Low, Helen Rutherford, and Clare Sandford-Couch, tackles the implications and effects of this transition. Growing out of a conference held in 2018, Execution Culture is divided into two sections: the first focuses on the act of witnessing the execution and the second on the ways that executions were represented after 1868. The volume also raises a fascinating analytical question: how do you write the history of an absence? This question is partly addressed in James Gregory's treatment of the ways that the Capital Punishment Amendment Act of 1868 was depicted first by contemporaries and later in both popular and scholarly cultures. But it runs throughout the volume as both a methodological and analytical question. The first part of the volume, "Going to see a man hanged," takes up issues that will be most familiar to scholars of punishment. Rachel Bennett (on Scotland) and Matthew White (on London) show the myriad ways that the hanging, as well as fears about the effects of hanging, played across the nineteenth century. They remind the reader that, despite the apparent sameness of executions, they were, in fact, extremely varied in their placement, in the tactics deployed to manage both the condemned and the crowd, in the reactions of crowds, and in the penalties inflicted on the condemned both in life and death. Katherine Ebury (on the effect of the Act on the ways executioners experienced and depicted their task) and Rhiannon Pickin (on contemporary prison museums in the United Kingdom) tackle the problem from a different perspective. Here the question becomes the gap between those who engaged in the execution and wrote about the experience and those who, presented with a virtual experience of seeing an execution, return little marked to their daily lives. In Britain, after all, the death penalty now exists largely in popular culture. Ebury and Pickin's chapters lead nicely into the second part ("One had better narrate the circumstances as they occurred"), which is a series of investigations into the ways that capital punishment has been conceived and represented after it was moved behind prison walls. Samuel Saunders (on the periodical press), Rutherford and Sandford-Couch (on the depiction of a violent offender), and Seth Low (on the initial years of the Capital Punishment Amendment Act) offer careful readings of the ways in which the press framed both the execution and the condemned and of how the Act changed the practices of execution itself. Rutherford and Sandford-Couch in particular draw attention to the fact that, as executions receded from visibility, other spaces (the coroner's court, the criminal trial) [End Page 511] became increasingly important venues to watch the play of justice and the reactions of the condemned. Their readings, combined with Low's analysis of the tensions between local and national authorities, remind us that the elimination of public hanging created new issues even as it purported to solve old ones. Finally, Stephanie Emma Brown (in a study of Wales) demonstrates the complexity of national and racial issues by demonstrating that there was no simple creation of a so-called Other...

Purpose Following deaths and hospitalisations in Melbourne, Victoria, Australia, related to the unwitting consumption of a combination of 25C-NBOMe and 4-FA, a community-led unauthorised drug checking service was rapidly established at a subsequent music festival. We aim to demonstrate the value of community-led drug checking, even when conducted in less-than-ideal conditions, by describing this service and reporting on its outcomes. Design/methodology/approach In all, 131 samples were tested with between 1 and 4 (M = 2.24 and SD = 0.61) reagents (Mandelin, Marquis, Mecke and Simons), and behavioural intentions of service users were reported. Findings People whose results indicated that the drug tested was what they expected, or was a drug familiar to them, were more likely to report an intention to take the drug compared to those whose results indicated that the drug was not what they had expected. For example, in 11 cases where the expected substance was not identified and novel substances including 2 C-X (including the NBOMe series), methylone, mephedrone, PMA and MXE were indicated, most reported an intention to discard (8/11). Practical implications The guerrilla service appeared to dissuade some people from consuming substances with higher risk profiles. It was also quick to identify substances of concern consistent with the NBOMe/4-FA combination for broader community action. The authors urge governments in Australia and elsewhere to reconsider their opposition to drug checking services, given their utility as vital health services during times of volatile drug market shifts. Originality/value While these data are five years old, it has only been in the past year that the Coroners Court of Victoria finalised their report on the deaths associated with this drug outbreak, providing context for the rapid peer response.

Objective(s): This study aimed to critically examine the circumstances contributing to, and the human costs arising from, the retention of surgical items through the lens of Australian case law. Design, setting and participants: We reviewed Australian cases from 1981 to 2018 to establish a pattern of antecedents and identify long-term patient impacts (human costs) of retained surgical items. We combined a systematic review of legal doctrine with a narrative synthesis approach. We searched for publicly available civil cases, medical disciplinary cases, coronial cases and criminal cases across all Australian jurisdictions. Results: Ten cases met the inclusion criteria – one coronial case, three civil appeal cases, six civil first instance cases. Time from item retention to discovery ranged from 12 days to 20 years, with surgical sponges the most frequently retained item. Five case reports indicated possible deviations from standard protocols regarding counting procedures and record-keeping. In the four cases that reported on count status, the count was deemed correct at the end of surgery. Case reports also showed the long-term impacts on patients associated with a retained surgical item. In eight of the nine civil cases, ongoing pain was the most frequently reported physical symptom; in three cases, patients suffered psychosocial symptoms requiring treatment. Conclusion: While there was little uniformity in the items retained or how items came to be retained, we identified significant time delays between item retention and item discovery, coupled with long-lasting physical and psychosocial harms suffered by patients living with a retained surgical item. Current prevention strategies, including national standards-based professional practices, are not always effective in preventing retained surgical items. An internationally standardised taxonomy and reporting criteria, more consistent reporting, and open access to event and risk data could inform a more accurate global estimate of risk and incidence of this hospital-acquired complication.

The association between unemployment and suicide among employed and unemployed people in Hong Kong: A time-series analysis

A Network Approach to Understand Co-Occurrence and Relative Importance of Different Reasons for Suicide: A Territory-Wide Study Using 2002-2019 Hong Kong Coroner's Court Reports

SUMMARYIt is highly likely that a psychiatrist will be called to an inquest at some point in their career. Our aim in this article is to educate psychiatrists in relation to the law and processes of a coroner's court in England and Wales and provide guidance on engaging with the system. To achieve this we review and discuss the relevant law and medico-legal aspects of inquests. Knowledge and preparation are key to negotiating any inquest and we would hope that the understanding and guidance offered in this article will reduce anxiety, make the situation manageable and aid professionalism, in often tragic circumstances.

Family violence homicide (FVH) is a major public health and social problem in Australia. FVH trend rates are key outcomes that determine the effectiveness of current management practices and policy directions. Data source-related methodological problems affect FVH research and policy and the reliable measurement of homicide trends. This study aimed to determine data reliability and temporal trends of Victorian FVH rates and sex and relationship patterns. FVH rates per 100,000 persons in Victoria were compared between the National Coronial Information System (NCIS), Coroners Court of Victoria (CCoV) Homicide Register, and the National Homicide Monitoring Program (NHMP). Trends for 2001-2017 were analysed using Joinpoint regression. Crude rates were determined by sex and relationship categories using annual frequencies and Australian Bureau of Statistics population estimates. NCIS closed FVH cases totalled 360, and an apparent downward trend in the FVH rate was identified. However, CCoV and NHMP rates trended upwards. While NCIS and CCoV were case-based, NHMP was incident-based, contributing to rate variations. The NCIS-derived trend was particularly impacted by unavailable case data, potential coding errors and entry backlog. Neither CCoV nor NHMP provided victim-age in their public domain data to enable age-adjusted rate comparison. Current datasets have limitations for FVH trend determination; most notably lag times for NCIS data. This study identified an indicative upward trend in FVH rates in Victoria, suggesting insufficiency of current management and policy settings for its prevention and control.