The WA Department of Health’s Patient Safety Surveillance Unit has just released From Death We Learn 2018. This annual publication seeks to promote education and improve awareness across the WA health system by highlighting key lessons learned from deaths resulting in coronial inquests. The 2019 edition outlines the health related coronial inquests that were reported in the 2018 calendar year. Many of these cases relate to mental health, and it is valuable for clinicians to consider these.
As per previous editions, From Death We Learn 2018 includes key messages and discussion points to encourage healthcare providers and organisations to reflect upon these in relation to their clinical practice and/or practice site. Where coronial recommendations have been made, these are outlined in the report along with a summary of the actions taken by the WA health system in response to these recommendations.
The report is accessible online, along with previous editions, on the Safety and Quality website.