How well do Regulation 28 reports serve future public health and safety?

Her Majesty’s (H.M.) coroners issue Regulation 28 (Reg. 28) reports following inquests. These reports concern hazards which, if mitigated, might prevent future deaths, and have addressees who are best placed to take remedial actions. Since 2013, the reports and addressees’ responses are copied to, and electronically published by, the Chief Coroner in non-exclusive demographic, aetiological or venue categories. Three of those categories were chosen so as to minimise the replication of unique cases – child deaths; alcohol, drugs and medications (ADM); and railways – with the most recent 50 reports in each category. A further ad hoc sample of neonates was taken after a finding in the first of these. The principal findings are: (a) H.M. coroners generate Reg. 28 reports at different rates (including 27 coroner areas with none at all; random variation probability p ≈ 10–6); (b) there is a large deficit of addressees’ responses compared with Reg. 28 reports that are issued; (c) addressees from large organisations are more likely to respond than small ones; (d) substantive remedial actions appear in only a further subset of addressees’ responses; and (e) there is a sex imbalance in Reg. 28 reports which is least explicable for neonates. It is concluded that the Reg. 28 report system is haphazard in many ways. As the only official publication from H.M. coroners’ courts, Reg. 28 reports have a large scope for improvement, which might promote support from bereaved families and the wider public for the process of inquest. Suggestions for process improvement are made.

Covid-19: statutory means of scrutinizing workers’ deaths and disease

Background By law, covid-19 disease and deaths in workers may lead to coroners’ inquests and/or Health and Safety Executive (HSE) investigations. Aims This study assesses the adequacy of these statutory means to yield recommendations for prevention of acquiring covid-19 infection from work. Methods Covid-19 guidance from the chief coroner and the HSE was appraised, including using Office for National Statistics (ONS) data. Practitioners were asked to estimate the likelihood that covid-19 disease may have arisen from ‘near-miss’ scenarios. Data from the judiciary and the HSE were analysed. Results The coroners’ guidance allowed a wider range of reports of death than did the HSE and conformed better with ONS data on covid-19 mortality by occupation. In the practitioner survey, 62 respondents considered a higher likelihood that reported covid-19 cases would have arisen from the scenario deemed unreportable as a ‘dangerous occurrence’ by HSE than the reportable scenario (P < 0.001). On average there was only one coroner’s report to prevent future death from occupational disease every year in England and Wales. The HSE dealt with a yearly average of 1611 reports of work-related disease including 104 on biological agents, but has received about 9000 covid-19 reports. Conclusions Current HSE guidance for reporting work-related covid-19 may miss many thousands of cases and needs further iteration. Coroners have very limited experience of inquiry into occupational disease caused by biological agents compared with the HSE. Concerns regarding national policy such as on protective equipment warrant a full public inquiry.

News Media Coverage of Stakeholder Views on Suicide and Its Reporting in New Zealand

Background: Periodically, a debate around suicide reporting becomes prominent in the media. At one point, the Chief Coroner of New Zealand made a public call to the media to open up discussions around suicide and its reporting. Following this action, a high-profile debate emerged in the media. Aims: Our aim was to identify the key players in this debate and examine their perspectives. Method: From a Factiva search of news items from high-circulation newspapers, we identified key stakeholders and documented their perspectives using a framing matrix. Results: Seven stakeholder groups were identified with coroners and health service providers dominant in the news. Framing around the issues varied. There was consensus among the majority of stakeholders supporting continued public health type coverage of the issue of suicide, but a number of differences in levels of support for the reporting individual suicides. Limitations: Although specific to New Zealand, the findings will be of interest to countries considering reporting restrictions. Conclusion: The debate around suicide and its reporting appears to have been obfuscated by the conflating of two different types of media reporting on suicide: news media coverage of suicide as a public health issue and the reporting of individual suicide cases.

Mortality and Morbidity in Office-Based General Anesthesia for Dentistry in Ontario

Our objective was to estimate the prevalence of mortality and serious morbidity for office-based deep sedation and general anesthesia (DS/GA) for dentistry in Ontario from 1996 to 2015. Data were collected retrospectively in 2 phases. Phase I involved the review of incidents, and phase II involved a survey of DS/GA providers. In phase I, cases involving serious injury or death for dentistry under DS/GA, sourced from the Office of the Chief Coroner of Ontario and from the Royal College of Dental Surgeons of Ontario (RCDSO), were reviewed. Phase II involved a survey of all RCDSO-registered providers of DS/GA in which they were asked to estimate the number of DS/GAs administered in 2015 and the number of years in practice since 1996. Clinician data were pooled to establish an overall number of DS/GAs administered in dental offices in Ontario from 1996 to 2015. Prevalence was calculated using phase I (numerator) and phase II (denominator) findings. The estimated prevalence of mortality in the 20-year period from 1996 to 2015 was 3 deaths in 3,742,068 cases, with an adjusted mortality rate of 0.8 deaths per 1 million cases. The estimated prevalence of serious morbidity was 1 injury in 3,742,068 cases, which adjusts to a serious morbidity rate of 0.25 per 1 million cases. The mortality rate found in this study was slightly lower than those published by earlier studies conducted in Ontario. The risk of serious morbidity was found to be low and similar to other studies investigating morbidity in office-based dental anesthesia.

Characteristics of Opioid-Related Deaths in Ontario, Canada: Leveraging the Drug and Drug/Alcohol Related Death (DDARD) Database

IntroductionReview of post-mortem toxicological results is the gold standard for identifying whether a death is opioid-related. The Drug and Drug/Alcohol Related Death (DDARD) database contains abstracted information from the Office of the Chief Coroner of Ontario, for all opioid-related deaths that occurred in Ontario, Canada between 1991 and 2016. Objectives and ApproachThe DDARD, which contains manner of death and drug concentrations from post-mortem toxicology results for opioids-related deaths in Ontario, was linked to the data repository housed at ICES. The objective of this project was to examine demographic characteristics and the type of opioid contributing to opioid-related deaths in FY2015/16. Individuals identified within DDARD who died from an opioid-related cause were linked to demographic, hospitalization and prescription drug databases to report on age, gender, neighbourhood income quintile, past health services utilization for opioid-toxicity, alcohol use disorders (AUD), mental health emergency department (ED) visits, and opioid(s) present at time of death. ResultsWe identified 737 opioid-related deaths in FY2015/16, the majority of which involved men (n=497; 67.4%), those living in lower socioeconomic status areas (n=395; 53.6%), and those residing in urban regions (n=655; 88.9%). Nearly half (n=325; 44.1%) of opioid-related deaths occurred among those aged 45 to 65 years. We found 9.5% (n=70) of individuals had a previous hospital visit for opioid toxicity, 25.4% (n=187) had previously diagnosed AUD, and 42.5% (n=313) had a previous mental health ED visit. Overall, 250 (33.9%) individuals had an active opioid prescription at time of death with oxycodone (n=92; 36.8%) the most commonly dispensed. Among those who didn’t have an active opioid prescription at time of death (n=484; 66%), fentanyl (n=184; 37.8%) was the most commonly found opioid on post-mortem toxicology. Conclusion/ImplicationsThis project demonstrates how data obtained through chart abstractions can be used to enhance existing administrative health datasets. Given the concern around the safety of opioids, it is important to examine the characteristics and type of opioid(s) involved at time of opioid-related death in order to develop targeted preventative strategies.

The Feasibility and Clinical Utility of Conducting a Confidential Inquiry Into Suicide in Southwestern Ontario

Background and Aims: Given the effectiveness of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI) in the UK, the present study evaluated this approach in Southwestern Ontario. A systematic confidential examination of suicides in Ontario was developed to guide quality improvement of services and suicide prevention. Method: A 3-year case series of consecutive suicides in Southwestern Ontario identified by the Office of the Chief Coroner was compiled. Clinicians who provided care to suicide decedents completed an online confidential suicide questionnaire offered through a secured portal. Results: A total of 476 suicide cases were analyzed. In all, 270 invitations to clinicians were sent, 237 (87.8%) responded to the invitation and 187 (69.3%) completed the online questionnaire. The majority of the suicide decedents (54.6%, n = 260), were between the ages of 40 and 64 (x = 47.2, SD = 17.1), White (91.4%, n = 416), single (34.2%, n = 439), and male (74.4%, n = 476). Of the 86 cases of self-poisoning, prescription medications were used in 66.3%. Almost two thirds of decedents visited the clinician in the month prior to their death. Limitations: The results of the survey were drawn from suicides in Southwestern Ontario and generalizing these findings should be done with caution. Conclusion: This study highlights (a) the value of the clinicians' survey to identify gaps in clinical services and (b) the necessity of improvements in suicide risk assessment/management and restriction of prescription medications.

Projects “Journey” and “Sunset” build connections for positive community impact

In 2011, the Office of the Chief Coroner for Ontario released the Death Review of the Youth Suicides at Pikangikum First Nation, 2006-2008 following an alarmingly high number of youth suicides that occurred in that community. Persistent social, health, infrastructure, economic, capacity, and governance deficits that exist contribute to vulnerability and atrisk behaviours among youth including crime, substance abuse, and suicide. The Ontario Provincial Police (OPP) sought ways and means to work to address these challenges in collaboration with communities. After securing funding support through Public Safety Canada, the OPP implemented an experiential youth development program called Project Journey, modelled after Project Venture, a program from the United States specifically designed for at-risk Indigenous youth. So promising are the results from Project Journey that a sister program, Project Sunset, came into being to help expand the proactive work with community partners. These OPP-led programs help address the root causes of youth crime, social disorder, and crisis. At the same time, they support relationship-building and community engagement, and empower individuals and community partners to take positive action for sustainable change.

‘I can't put that on paper.’ How medical professional values shape the content of death certificates

This paper follows collegiality, demonstrating how, as a central value of medically trained coroners, it can shape the content of death investigations and certificates. Drawing on ethnographic evidence from a 16-month-long study of the Office of the Chief Coroner (OCC) of Ontario, Canada, I argue that collegiality is an instrument of trust that both affords investigators tremendous access to information, and severely limits the flow of that information into the public domain that the OCC serves. The paper focuses on in-care death investigations, which are those where the OCC's medically qualified coroners find themselves investigating the quality of care delivered by professional colleagues. I show how professional expertise, experience and collegial values often combine to see instances of poor or even incompetent care dealt with privately (rather than publicly) or referred up the medical (rather than public safety) hierarchy. The burden of my argument is that collegial deference to the autonomy and skills of other physicians tends to see coroners expurgate the death certificates they produce. These expurgations obscure competence issues from public view and reduce the accuracy of the certificates. I close with a discussion of the benefits and drawbacks of medically qualified death investigators, as well as potential adjustments to improve the accuracy of in-care death investigations and certifications.

Medications Without a Patient

Background: Little has been published on the sources of medications used in suicide by self-poisoning. Aims: To examine data on self-poisoning occurring through the use of medications returned to the next of kin after the death of a family member or friend (”returned medication”) and to examine public policies relevant to this issue. Method: A review of charts at the Office of the Chief Coroner of Ontario for deaths by self-poisoning suicide in the City of Toronto occurring between 1998 and 2010 was conducted. Information regarding the source of medication used in self-poisoning was extracted. Federal, provincial, and local policies were also examined to determine whether there are guidelines governing returning medication to next of kin. Results: Of 567 suicide deaths by self-poisoning in Toronto over 13 years, there were eight cases in which returned medication was used in suicide by self-poisoning. No policies prohibiting this type of medication return were identified. Conclusion: Suicide by self-poisoning using returned medications is an important consideration that may not yet be fully appreciated, and has relevance for suicide prevention policies.