Coroners

The Salt-Overly-Sensitive (SOS) pathway controls the net uptake of sodium by roots and the xylematic transfer to shoots in vascular plants. SOS3/CBL4 is a core component of the SOS pathway that senses calcium signaling of salinity stress to activate and recruit the protein kinase SOS2/CIPK24 to the plasma membrane to trigger sodium efflux by the Na/H exchanger SOS1/NHX7. However, despite the well-established function of SOS3 at the plasma membrane, SOS3 displays a nucleo-cytoplasmic distribution whose physiological meaning is not understood. Here, we show that the N-terminal part of SOS3 encodes structural information for dual acylation with myristic and palmitic fatty acids, each of which commands a different location and function of SOS3. N-myristoylation at glycine-2 is essential for plasma membrane association and recruiting SOS2 to activate SOS1, whereas S-acylation at cysteine-3 redirects SOS3 toward the nucleus. Moreover, a poly-lysine track in positions 7-11 that is unique to SOS3 among other Arabidopsis CBLs appears to be essential for the correct positioning of the SOS2-SOS3 complex at the plasma membrane for the activation of SOS1. The nuclear-localized SOS3 protein had limited bearing on the salt tolerance of Arabidopsis. These results are evidence of a novel S-acylation dependent nuclear trafficking mechanism that contrasts with alternative subcellular targeting of other CBLs by S-acylation.

In the wake of tragic events involving emergency service response, society has increasingly moved to the process of post-mortem inquiries with the goal of identifying errors and avoiding future deaths. While the goals of public accountability and quality assurance are laudable, these inquiries do not come without cost. The results of this qualitative study of 37 emergency workers who had been involved in inquiries, suggest that they have a profound effect. Participants in this study identified experiences of feeling unprotected, attacked and presumed guilty of incompetence or negligence when testifying at a postmortem review. These feelings were intensified by the media attention, which was often sensational and vilifying and the subsequent public response of suspicion and blame. They were further intensified by what participants viewed to be an unsupportive organizational response. The result was feelings of betrayal, anger and reduced commitment. Strategies for ensuring that inquiries do not undermine quality service include proactive support, education and legal representation.

Police tell stories to make sense of their experiences but also, as this paper argues, they tell stories to establish legal doctrines and support justifications for their decisions. Departing from police ethnography and narrative criminology, adopting a deconstructive and critical Black Studies perspective, this paper reads the narrative W80 (a London Met police firearms officer) provided in the inquiry into the death of Jermaine Baker, a 28-year-old Black man, in 2015, to examine how uncertainty was both conditional and functional in the narrative to sustain the justification of racial violence. W80's narrative reveals how causality undergird the law of self-defence he cited and related on. Problematising the distinction of story and action, this paper analyses W80's narrative for its thematic of fiction and truth. Attending to this, the paper argues the conditions of uncertainty and open-endedness of W80's narrative reserved for racial violence to be reasoned and justified as lawful.

to conduct a three-year study on this topic. The overall question posed by DFCS was: What are the primary reasons why children of color are disproportionately represented in Santa Clara County's Child Welfare System? In order to address the complexity of this question, the CWRT elected to employ a multiphase/multimethod approach, beginning with an initial exploratory phase that was completed in May 2001. Data for Phase 1 were gathered from three sources: research literature at the national, state and county levels; Santa Clara County's management information system (CWS/CMS); and focus group discussions with professionals in Santa Clara County who provide child welfare services, as well as parents, caregivers and youth who are recipients of CWS services. Four central themes emerged from Phase 1 findings (please see Phase 1 Final Report for a complete description of the findings from which these themes were generated). Conclusions from Phase 1 indicated that more research was needed that focused on the actual experiences of children in care and the individual and family-related i

The Salt-Overly-Sensitive (SOS) pathway controls the net uptake of sodium by roots and the xylematic transfer to shoots in vascular plants. SOS3/CBL4 is a core component of the SOS pathway that senses calcium signaling of salinity stress to activate and recruit the protein kinase SOS2/CIPK24 to the plasma membrane to trigger sodium efflux by the Na/H exchanger SOS1/NHX7. However, despite the well-established function of SOS3 at the plasma membrane, SOS3 displays a nucleo-cytoplasmic distribution whose physiological meaning is not understood. Here, we show that the N-terminal part of SOS3 encodes structural information for dual acylation with myristic and palmitic fatty acids, each of which commands a different location and function of SOS3. N-myristoylation at glycine-2 is essential for plasma membrane association and recruiting SOS2 to activate SOS1, whereas S-acylation at cysteine-3 redirects SOS3 toward the nucleus. Moreover, a poly-lysine track in positions 7-11 that is unique to SOS3 among other Arabidopsis CBLs appears to be essential for the correct positioning of the SOS2-SOS3 complex at the plasma membrane for the activation of SOS1. The nuclear-localized SOS3 protein had limited bearing on the salt tolerance of Arabidopsis. These results are evidence of a novel S-acylation dependent nuclear trafficking mechanism that contrasts with alternative subcellular targeting of other CBLs by S-acylation.

I attended the first Legal aspects of surgical practice course held at the Royal College of Surgeons of England. This one day course, covering red flag situations, was convened by Paul Marks, consultant neurosurgeon and deputy coroner for West Yorkshire. Who is it for? This course is suitable for doctors at all levels. Most of the 50 attendees when I took the course were registrars, many of whom were approaching their exit exams, but there were also a large number of consultants (including professors). Junior trainees (foundation doctors and core trainees) may not benefit as much as middle tier and senior staff.

AimsTo examine in detail a series of coproxamol overdose deaths in order to provide information that will assist in the development of strategies to prevent such fatalities.MethodInquest records in 24 coroners’ jurisdictions in England on deaths between January 2000 and December 2001 which received a verdict of either suicide or undetermined cause (with a high or moderate probability of suicide) were examined.ResultsOne hundred and twenty‐three coproxamol poisoning suicides were identified. Alcohol was involved in 58.5% of the overdoses and these individuals generally had lower blood drug levels and consumed fewer tablets. Younger people were more likely to have consumed alcohol and to have lower levels of suicide intent. Nearly half the individuals had a history of self harm, and a third were under psychiatric care. The coproxamol had been prescribed for the individual in 81.5% of cases, although only in 55.0% of those aged 10–34 years. In other cases the source of the coproxamol w...

This article examines some of the possible harmful effects of regulatory investigations, in particular that of trauma, on persons being investigated and those around them, the legal, ethical or regulatory duties or responsibilities of regulators in the case of such events, and programs currently available to prevent or ameliorate these effects. It concludes by describing what trauma-informed regulatory practice might look like and concludes that a trauma-informed approach to regulation can provide a model of justice that can be applied to persons adversely affected by investigations without derogating from a regulator's statutory purposes.

Suicide is a major concern for mental health nurses because of its clear correlation with mental illness. In New Zealand, coroners investigate all deaths that appear to be a result of suicide, and provide reports to mental health services (MHS). The aim of the present study was to investigate coronial recommendations to MHS in relation to suicide prevention and to examine clinical and family responses to these. The present study was a three-phase design: (i) analysis of coroners' recommendations related to suicide in MHS; (ii) interviews with clinicians for their response to the recommendations; and (iii) interviews with individuals working with families of consumers of MHS for their responses in relation to family-related recommendations. A qualitative content analysis was conducted on the recommendations from coroners, the interviews with clinical leaders, and the focus group for family workers. Coroners recommended that MHS should implement suicide-prevention strategies that would facilitate improved communication, risk containment, service delivery, and family involvement. Clinicians agreed with most recommendations, apart from those related to risk containment. Family workers endorsed the coronial perspective that family inclusion in MHS was suboptimal. Coroners, MHS, and mental health nurses need to consider the latest clinical evidence for suicide prevention. However, given the complexity of factors that influence suicide, it is important to be realistic about MHS role in preventing suicide, but ensure that MHS provide interventions for which there is evidence, including facilitating family participation and providing access to psychotherapies.

The contentions in this paper arose tangentially from a study of London coroners I began in the summer of 1998. I had intended to examine the verdicts from nineteenth-century coroners' courts in order to assess the differences in verdicts that might arise depending on whether the coroner was a doctor, a lawyer, or neither. Was a physician more likely to detect murder as a cause of death than a lawyer or a ''civilian?'' Instead, as I read hundreds of inquest reports and explored the history of the coroners' courts, I began to realize that

The ETHICS column explores issues around practising ethically in primary health care and aims to encourage thoughtfulness about ethical dilemmas that we may face. THIS ISSUE: This issue focuses on media reporting of suicide and aspects other than safety that warrant consideration.

We aimed to demonstrate how a large collection of publicly accessible Australian Coroner’s Court case files (n=4459) (2009-2019) can be automatically classified for determination of death by suicide, presence of mental health disorder and sex of deceased via Natural Language Processing (NLP) methods - supervised machine learning and unsupervised dictionary-based and string search based approaches. We achieved superior levels of accuracy in the machine learning classification (Gradient Boosting vs. Random Forest baseline) of deaths by suicide of 83.3% (sensitivity = 85.1%, Specificity = 79.1%) and an accuracy of 98.3% for the dictionary-based classification of mental health disorder, as defined by the OCD-10 (sensitivity = 99.0%, specificity = 97.9%). Our machine learning approach automatically classified 24.2% (1078/4459) of the case files as referring to deaths by suicide while 63.7% (2940/4459) where classified as exhibiting a mental health disorder1. We employed a two-stage machi...

However, they can take place after the resolution of criminal charges and, although coroners' findings cannot be expressed in terms of persons' criminality, inquests can also result in referrals to prosecuting authorities. In addition, referrals to professionals' disciplinary regulators can be made by coroners. The potential for such adverse outcomes for the individuals affected makes it essential for those representing parties or witnesses at coronial hearings to consider carefully the forensic strategies that they deploy and, in particular, the advice that they provide, including in relation to claims to the privilege against self-incrimination. By reason of the partial abolition of the doctrine of autrefois acquit in a number of Australian jurisdictions, the potential for new and compelling evidence to emerge during an inquest takes on additional significance for persons who have been found not guilty of offences such as a murder at a previous trial.

Deaths of participants in sport from the effects of concussive injuries and from chronic traumatic encephalopathy (CTE) raise confronting social issues and challenges for tort law. An uncertainty that often needs to be addressed in such cases is proof of the causes of the former athlete’s symptomatology, especially when they may be multifactorial, some or all of which were not directly related to sport. Accounts from the person prior to their death and from family members can be vital sources of such information. Coroners’ analyses of evidence in concussion-related deaths constitute an important opportunity for perspectives which can form a sound empirical basis for changes to sporting practices, rules and administration. This editorial reviews a series of biographical and autobiographical accounts of sportspersons with concussion and CTE. It also identifies a corpus of coronial decisions from England, New Zealand, Canada and Australia which have addressed the risks posed to athletes from concussive injuries. It highlights recommendations made by coroners in relation to management of concussion in sport and argues that there is considerable scope for further valuable recommendations based upon their investigations during inquests.

She has accurately reported many of the opinions and recommendations voiced at this conference. However, the statement "doctors should encourage patients to discuss drug products with pharmacists, though only with those who are known and trusted by both the patient and physician" should read "doctors should. who are known and trusted by the patient". The medical profession relies on the help and goodwill of community pharmacists, and no doubts as to their integrity were expressed at this conference.

A series of Freemason Judges' Errors Of Law decisions persecute the family for demanding Justice CHAPTER 1: Introduction-Freemason army of Judges persecute the family, for seeking justice into Sunaina's highly suspicious and sudden death, in an NHS hospital, at the hands of doctors, in British Courts. Way back, in the days of King Richard II, Old John of Gaunt, was, according to Shakespeare, obliged to cry out against injustice thus, "This land of such dear dear souls, dear land, Dear for her reputation through the world Is now leas'd out-I die pronouncing it-Like to a tenement or pelting farm". What was felt about England then, is what many of us now feel about out courts! Very few of our judges are still committed to ensure justice in our court. Many of them seem to be leasing out justice like a tenement or a pelting farm. Hence, the sum total, of this website is about the ways some of our judges, by virtue of their membership of Freemasonry, have perverted the course of justice in our dear, dear land. TO BE OR NOT TO BE When my sister Sadhana Dolly Chaudhari, a postgraduate certificated science teacher, and I, a pharmacist, found ourselves greatly afflicted by the death of baby Sunaina Chaudhari, my niece, and Chaudhari's daughter, we sought guidance from the Holy Writ. Now and then, quotations from Shakespear turned out to be very useful. For instance, to be or not to be, became the question with us. Were we to suffer the outrageous fortune brought by the killing of the five month old baby Sunaina or were we to take up arms against a sea of misfortune and by opposing them, end them? We decided to take up arms against a sea of misfortune. But what kind of arms were we to take? REPORTING OFFENCE The answer to that question was easy. The greatest philosopher, Socrates had given it. Though he had lived for the edification of mankind, yet he was sentenced to die for corrupting the youth. Although some of those who sentenced him to die wanted him to flee the country and escape death, yet, he refused to save his life saying something to the effect that, "Since I have lived by the law, it is only right that I die by the law too".

Using medicines purchased online without therapeutic advice can lead to outcomes such as treatment failure, antimicrobial drug resistance, adverse drug reactions and deaths. We have reviewed the factors associated with 17 deaths, which UK coroners deemed preventable, in individuals who used medicines purchased online. This article is part of the Coroners' Concerns to Prevent Harms series. 1 It highlights problems that can arise from using medicines purchased online, exemplified by 16 Prevent Future Death reports relating to 17 individuals.

Since the 1980s, a number of fair trial rights and civil liberties have been eroded in Australia, particularly in respect to summary justice and police powers. This article traces the 'bottom-up' origins of some of those rights and liberties in colonial New South Wales. It focuses on the activist Edwin Withers and his interactions with the Parramatta magistracy in the mid 1840s. The Withers example enables us to see how some fair trial rights and civil liberties resulted from community-based social activism, which relied upon the legislature and higher court authority to become law. The importance of these rights-for example, the right to counsel, the right to a fair and impartial tribunal and protection against arbitrary detention-is demonstrated by the very fact that they issued from the working and middle classes and are implicated within wider class relationships involving residents of a local community. Using archival research and qualitative analysis, this article has important implications for Australian legal history in relation to the adoption of the Jervis Acts 1848 (UK), some of the first summary procedure legislation enacted within colonial NSW. The article demonstrates how the fair trial rights campaign at Parramatta resulted in amendment to the adopted Acts in the colony.

et al. A crosssectional survey using electronic distribution of a questionnaire to subscribers of educational material written by clinicians, for clinicians, to evaluate whether practice change resulted from reading the Clinical Communiqué. BMJ Open 2017;7:e014064.

We write as experienced paediatric practitioners who have been involved in medico-legal proceedings where cases related to childhood cancer practice have featured frequently. We will use the service evaluation of Professor David A Walker’s last 35 cases, where all but seven concerned children with tumours of the brain or spine to illustrate the concerns that families raise. We refer to the evidence from the HeadSmart programme (www.headsmart.org.uk), which seeks to accelerate diagnosis by raising awareness of the disease and symptoms. We use the experience of Dr Jonathan AG Punt to illustrate the legal issues that apply and explain the way that significant quantum calculations are applied to cases of this type. The current move by NHS Resolution to explore the expanded role of mediation will be discussed and the need for research to explore the precise way that mediation could be developed to offer an alternative approach to conflict resolution.

Fatal work incidents result in an array of government responses, and in countries such as the United Kingdom and Australia, this may include the holding of coronial inquests. A common theme from the scant literature is that family members have a strong need to know how and why their loved one died. The inquisitorial nature of inquests suggests potential in uncovering this information, although little is known about families' experiences with these proceedings. Interviews with 40 bereaved relatives explored their views and experiences of inquests. Findings suggest that families, often frustrated with other investigative processes, want inquests to provide a better understanding of how and why the death occurred, uncover any failings/ responsibilities, and thereby move closer to a sense of justice being obtained for the deceased. Families identified problems perceived to impair the process and where improvements could be made to secure a more effective and meaningful institutional response to the fatality.

This study aimed to describe the perceived barriers faced by emergency clinicians in utilising mental health legislation in Australian hospital emergency departments. A semi-structured interview methodology was used to assess what barriers emergency department doctors and nurses perceive in the operation of mental health legislation. Key findings from the interview data were drawn in accordance with the most commonly represented themes. A total of 36 interviews were conducted with 20 members of the Australasian College for Emergency Medicine and 16 members of the College for Emergency Nursing Australasia representing the various Australian jurisdictions. Most concerning to clinicians were the effects of access block and overcrowding on the appropriate use of mental health legislation, and the substandard medical care that mental health patients received as a result of long periods in the emergency department. Many respondents were concerned about the lack of applicability of mental ...

The Trees was founded and it contradicts its main founding principles. The aim of the article is to demonstrate how the writer of the twentytruth through the violence of lynching. As the novel is both a detective fiction and a horror fantasy, the article shows that through these genres, the story exceeds white cruelty and black victimhood to understand black agency. The article asserts that the theory Everett presents is that in order to perceive a black body, there must be a white one. In The Trees terrorism disguising as police procedural and comedy, Everett provides a satirical narrative answer m deferred does explode, fall and descend. This witty novel of revenge and reckoning is a narrative condemning racial violence with strokes, and what stands at its core is the idea that Black deaths matter.

Within coronial investigations, pathologists are called upon to given evidence as to cause of death. This evidence is given great weight by the coroners; after all, scientific 'truth' is widely deemed to be far more reliable than legal 'opinion'. The purpose of this paper is to examine the ontological and epistemological status of that evidence, from the perspectives of both the pathologists and the coroners. As part of an Australian Research Council Linkage Grant, interviews were conducted with seven pathologists and 10 coroners from within the Queensland coronial system. Contrary to expectations, and the work of philosophers of science, such as Feyerabend (1975), pathologists did not present their findings in terms of unequivocal facts or objective truths relating to causes of death. Rather, their evidence was largely presented as 'educated opinion' based upon 'the weight of evidence'. It was actually the coroners who translated that opinion into 'medical fact' within the proceedings of their death investigations, arguably as a consequence of the administrative necessity to reach a clear-cut finding as to cause of death, and on the basis of their own understanding of the ontology of medical knowledge. These findings support Latour's (2010) claim that law requires a fundamentally different epistemology to science, and that science is not entirely to blame for the extravagant truth-claims made on its behalf.

In common law countries like England, Australia, US, and Canada, certain deaths come to be investigated through the coronial system. These include sudden, unnatural or suspicious deaths as well as those which appear to be the result of naturally occurring disease but the precise cause is unknown. When a reportable death occurs in Australia, a number of professional groups become involved in its investigation-police, coroners, pathologists, counsellors. While research has demonstrated the importance of training and education for staff in the context of criminal investigations-with its over-representation of vulnerable and marginalised populations-this is less likely to occur in the context of death investigations, despite such investigations also involving the over-representation of vulnerable populations. This paper, part of larger funded research on the decision making of coronial professionals in the context of cultural and religious difference, explores the ways in which cultural and religious minority groups-in this case Islam, Judaism and Indigeneity-become differently positioned during the death investigation based upon how they are perceived as 'other'. Our research raises three issues. First, positioning as 'the other' is dependent on the professional training of the staff member with police and pathologists far more likely than coroners to be suspicious or ignorant of difference. Second, specific historical and contemporary events effect the othering of religious and cultural difference. Third, the grieving practices associated with religious and cultural difference can be collectively othered through their perceived opposition to modernity.

Pickering makes several interesting and incisive points. We wish to comment on his suggestions regarding our analogy between organ procurement and post-mortem examinations, and regarding the putative duty to donate one's organs. First, a clarification of our view. We do not claim that reforming consent requirements would certainly increase organ availability and thus save more lives. However, there are good reasons to suppose that it would, based both on statistics from New Zealand and from abroad. This creates a strong initial case for further reform.

Pickering makes several interesting and incisive points. We wish to comment on his suggestions regarding our analogy between organ procurement and post-mortem examinations, and regarding the putative duty to donate one's organs. First, a clarification of our view. We do not claim that reforming consent requirements would certainly increase organ availability and thus save more lives. However, there are good reasons to suppose that it would, based both on statistics from New Zealand and from abroad. This creates a strong initial case for further reform.

The medicolegal death investigation in Victoria, Australia is a traditional coroner system based on the model in England and Wales in the early 20th Century. In 1985, the first of a series of legislative amendments were made that proved the vanguard of reform of the coroners' jurisdictions in Australia. The Victorian Institute of Forensic Medicine (the Institute) was established by the Coroners Act 1985 (Vic.), now the Victorian Institute of Forensic Medicine Act 1985 (Vic.), to provide forensic pathology, medical, and related scientific services needed by the justice system. In addition to death investigation, other forensic and scientific services are performed by the Institute including: clinical medical examinations and support services for assault victims and perpetrators, forensic toxicology services and molecular biology, and anthropology and odontology services in relation to human identification. Medical and nursing staff provide medical information and support to families in a therapeutic setting, as well as direct referral to clinical medical specialists. This takes place where a medical death investigation procedure uncovers genetic or familial disease that may place other family members at risk of future illness. A donor tissue bank ensures that a death also provides the opportunity for families to donate organs and tissues from the deceased for transplantation. Today, the traditional autopsy is one of several modalities of death investigation with postmortem radiology and imaging playing a significant role. This paper describes the principles and new processes at the Institute that support the coroner in death investigation and prevention as well as the therapeutic services designed to relieve the burden of disease on the community.

The National Coronial Information System (NCIS) is the world's first national Internet-based database of coronial information. It was established in Australia following the recognition by coroners that their mandate for public health and safety could be improved if they could identify previous similar deaths. The NCIS is funded from state, territory, and commonwealth government agencies and overseen by the NCIS Board of Management. A team of ten staff manage the day-today operation of the system. The NCIS enables the rapid identification of up-to-date information on deaths investigated by the coroners' jurisdictions in Australia (from July 2000) and New Zealand (from July 2007). It is accessible to death investigators (coroners; forensic, medical, and scientific staff; and police) to assist with death investigation and approved third parties (e.g., researchers). The NCIS contains demographic information about the deceased, contextual information about the circumstances in which the death occurred, the cause and manner of death, and four full text reports generated during the investigation. The NCIS contains information on over 328 000 completed coroners' death investigations across Australia and New Zealand. Approximately 350 death investigators are registered to access the data for their ongoing death investigations, and 235 third party users are registered to utilize the data set in their research. In addition to the utility of the NCIS, this paper describes the rationale and governance structure of the NCIS, the information technology infrastructure, data set, quality assurance framework, and contribution to death and injury prevention.

Background. 'Under-reporting' of deaths to the coroner has significant implications for the identification and investigation of preventable deaths. In extreme cases, it may even be a symptom of the system failures that allowed cases such as Harold Shipman, Australia's King Edward Memorial Hospital, the alleged incidents at the Bundaberg Hospital and the Bristol Royal Infirmary to persist. Several initiatives in Australia and the UK are currently reviewing the coroner's system in light of the recommendations made by the Luce report and the Bundaberg Hospital inquiry to consider whether the coroner's system effectively meets the needs of our society, including the healthcare sector. Reporting of deaths to the coroner is a key issue for consideration in this debate. Objective. This study's primary aim is to identify the number of deaths in the hospital setting that meet the reporting criteria set out by the coroner's Act, Victoria 1985 ('reportable deaths'). Method. This study utilized a method of retrospective structured medical record review of in-patients who died between 1 January 2002 and 30 June 2003 at two major public hospitals in Victoria, Australia. Results. In total, 229 cases (95.4% of records requested) were included in this review (120 from Hospital A and 109 from Hospital B). The number of cases at both hospitals meeting the coroner's reporting criterion was 58, of which, 22 (37.9%) were reported to the coroner. Conclusion. This study provides the first experimental evidence of significant 'under-reporting' of deaths to the coroner by hospitals. This is an important consideration for the reform initiatives currently underway. Better communication channels need to be fostered between doctors and coroners if coronial investigations are to be used effectively for reviewing deaths in hospitals.

Background: Medico-legal death investigations are a recognised data source for public health endeavours and its accessibility has increased following the development of electronic data systems. Despite time and cost savings, the strengths and limitations of this method and impact on research findings remain untested. This study examines this issue using the National Coronial Information System (NCIS). Methods: PubMed, ProQuest and Informit were searched to identify publications where the NCIS was used as a data source for research published during the period 2000-2014. A descriptive analysis was performed to describe the frequency and characteristics of the publications identified. A content analysis was performed to identify the nature and impact of strengths and limitations of the NCIS as reported by researchers. Results: Of the 106 publications included, 30 reported strengths and limitations, 37 reported limitations only, seven reported strengths only and 32 reported neither. The impact of the reported strengths of the NCIS was described in 14 publications, whilst 46 publications discussed the impacts of limitations. The NCIS was reported to be a reliable source of quality, detailed information with comprehensive coverage of deaths of interest, making it a powerful injury surveillance tool. Despite these strengths, researchers reported that open cases and missing information created the potential for selection and reporting biases and may preclude the identification and control of confounders. Conclusions: To ensure research results are valid and inform health policy, it is essential to consider and seek to overcome the limitations of data sources that may have an impact on results.

To describe the nature and extent of external-cause deaths of residents of nursing homes in Victoria, Australia. DESIGN: A retrospective cohort study of all decedents using routinely collected data contained within the National Coronial Information System. SETTING: Accredited nursing homes in Victoria. PARTICIPANTS: Nursing home residents who had died from external causes and whose deaths were reported to the Coroners Court between July 1, 2000, and December 31, 2012. MEASUREMENTS: Basic descriptive analysis was conducted to measure frequencies and proportion of exposures within each outcome group, and rates were calculated using population data. RESULTS: One thousand two hundred ninety-six external cause deaths of nursing home residents were identified. Deaths were due to falls (n = 1,155, 89.1%), choking (n = 89, 6.9%), suicide (n = 17, 1.3%), complications of clinical care (n = 8, 0.6%) and resident-on-resident assault (n = 7, 0.5%). Deaths occurred more frequently in women (n = 814, 62.8%), in keeping with the sex distribution in nursing homes, and residents aged 85 and older (n = 923, 71.2%). The number of inquests held to investigate a death as a matter of public interest was small (n = 24, 1.9%). CONCLUSION: A significant proportion of nursing home resident deaths are from external causes and are potentially preventable. A shift in community attitudes is required toward an understanding that premature death of a resident from injury is not a natural part of life.

Aim: This study provides a descriptive epidemiological analysis stratified by age of deaths reported to Australian Coroners of residential aged care facility residents aged under 65 years. Method: A national population-based retrospective analysis was conducted of deaths of Australian residential aged care facility residents reported to Australian Coroners between 2000 and 2013. Descriptive statistics compared adult residents categorised using age by factors relating to the individual, incident and death investigation. Results: Of the 21,736 deaths of residential aged care facilities residents aged over 20 years reported to Australian Coroners, 782 (3.6%) were of residents aged 20-64 years. Natural cause deaths occurred at similar rates irrespective of age. Intentional external cause deaths were higher in residents aged 20-64 years (5.3% vs. 16.0%; OR 3.43, 95% CI 2.0-5.9; p < 0.001), with suicide rates three times that of the over 65 years group (13.2% vs. 4.1%; OR 0.28, 95% CI 0.16-0.51; p < 0.001). External cause deaths from choking and falls were most common in the younger and older groups respectively. Conclusions: More is required to prevent external cause deaths in young residential care facility residents. ä IMPLICATIONS FOR REHABILITATION One in seven (14.1%) deaths of people aged 20-64 years in residential aged care facilities are premature and potentially avoidable. The more common external causes of death include suicide, choking and falls. The prevalence and causes of preventable deaths in this study provide a basis for prompting and developing more specific prevention policies and practices to reduce harm for young people in residential aged care. Specifically, addressing loneliness would improve social inclusion, mental health and suicide risk. Better management of progressive neurological conditions with multidisciplinary team and re-ablement programs would reduce risk of choking and falls. Improving outcomes for young people in residential aged care requires a coordinated , multisector approach comprising relevant government departments, aged care providers, researchers and clinicians. Effective planning requires more information about the cause and nature of deaths, and due to the small event counts, this would ideally involve an international collaboration.

The medicolegal death investigation in Victoria, Australia is a traditional coroner system based on the model in England and Wales in the early 20th Century. In 1985, the first of a series of legislative amendments were made that proved the vanguard of reform of the coroners&#39; jurisdictions in Australia. The Victorian Institute of Forensic Medicine (the Institute) was established by the Coroners Act 1985 (Vic.), now the Victorian Institute of Forensic Medicine Act 1985 (Vic.), to provide forensic pathology, medical, and related scientific services needed by the justice system. In addition to death investigation, other forensic and scientific services are performed by the Institute including: clinical medical examinations and support services for assault victims and perpetrators, forensic toxicology services and molecular biology, and anthropology and odontology services in relation to human identification. Medical and nursing staff provide medical information and support to famil...

Suicide may be conceptualized as an escape from intolerable predicaments, in particular, mental illness and environmental stressors. The operationalized predicaments of suicide (OPS) is a 4 category framework designed to assist in the classification of suicide. The objective was to examine whether this framework is potentially useful. 18 psychiatrists from 6 different countries examined 12 written coroners&#39; reports of suicide and rated each report according to the OPS. 16 of these raters then also completed a qualitative questionnaire regarding the framework. In 89.8% of cases the raters where able to make a decision regarding the drivers which led to the suicides. The respondents displayed modest inter-rater correlation (Kappa = 0.42; P &lt; 0.0001). In the qualitative section, respondents supported the face validity of OPS and considered it potentially useful. Feedback allowed improved wording of the OPS instructions. The OPS has potential as a useful framework. The OPS instru...

Introduction: In order to reduce transmission of COVID-19, in March 2020 the UK national and devolved governments imposed restrictions including spatial distancing, stay-at-home orders, and travel restrictions. The aim of this study is to compare the characteristics of cases referred to the Coronial system for autopsy in the months before and during the lockdown period. Methods: In all, 580 autopsy cases, performed in the London area between January and June 2020 were included in the study. Results: In the postlockdown period, there was an increase in the proportion of black individuals referred for autopsy, which just attained statistical significance (p ¼ 0.047). The proportion of decomposed bodies submitted for examination was significantly increased (p ¼ 0.011). The study did not show a significant increase in the proportion of out-of-hospital (community) deaths, traumatic deaths, or deaths due to alcohol or drug abuse or overdose. Conclusion: The study shows no evidence that COVID-19 preventative measures led to a change in the causes of death referred to the Coroner, except, of course, for COVID-related deaths. The proportion of black people among subjects for autopsy increased, probably because of a relatively higher incidence of COVID deaths among this group. Decomposed subjects were more common, probably due to social isolation.

This paper was sumitted to the SLS in 2022.
This paper begins by identifying the State’s legal obligations to prevent future deaths under human
rights law. It then examines the law surrounding recommendations issued following inquests and
public inquiries. The paper then explores some of the legal and practical mechanisms in different
areas where recommendations are routinely followed up and implemented, including air accidents
and military accidents. The paper explores whether these mechanisms could be applied more widely
to ensure the recommendations of coroners and public inquiries are followed up and implemented.
Finally, the paper discusses proposals from the NGO INQUEST to establish a National Oversight
Mechanism to ensure that recommendations to prevent future deaths are followed up and
implemented.

Accurately identifying death and its causes is integral to the compilation of mortality data and ultimately to the operation of the criminal justice and public health systems. A clear understanding of who is in charge of such processes is paramount to establishing the quality, or lack thereof, of the information provided in death certificates. Our study provides a comprehensive overview of all state statutes identifying death investigators charged with classifying and certifying death in the United States. We found that state statutes designate a broad range of individuals as responsible for the classification and certification of death. Those vary by state and set of circumstances and can include medical examiners, coroners, pathologists, other physicians, registered nurses, and more. Our findings highlight the important need for a unified standard of qualifications in the medico-legal system, as well as, regulatory reform at the state level regarding who can complete and sign deat...

to conduct a three-year study on this topic. The overall question posed by DFCS was: What are the primary reasons why children of color are disproportionately represented in Santa Clara County's Child Welfare System? In order to address the complexity of this question, the CWRT elected to employ a multiphase/multimethod approach, beginning with an initial exploratory phase that was completed in May 2001. Data for Phase 1 were gathered from three sources: research literature at the national, state and county levels; Santa Clara County's management information system (CWS/CMS); and focus group discussions with professionals in Santa Clara County who provide child welfare services, as well as parents, caregivers and youth who are recipients of CWS services. Four central themes emerged from Phase 1 findings (please see Phase 1 Final Report for a complete description of the findings from which these themes were generated). Conclusions from Phase 1 indicated that more research was needed that focused on the actual experiences of children in care and the individual and family-related i