Circular details

Annual (2008) Edition of From Death We Learn

The purpose of this Information Circular is to promote and circulate information about the 2008 edition of From Death We Learn.  The 2008 edition was written and prepared by the Coronial Liaison Unit (CLU) in the Office of Safety and Quality in Healthcare.

The health system endeavours to minimise the occurrence of adverse events and to optimise patient safety.  Investigations of unexpected or preventable deaths that have progressed to coronial investigation provide valuable insight into the way the health system works.  Results of coronial inquests are shared amongst health professionals to raise awareness and as a means to educate health professionals about the lessons learned from unexpected and preventable deaths.

Each year, the CLU produces a series of vignettes in the form of a single booklet that highlight unusual and/or significant outcomes from coronial inquiries and other investigations following death.  Production of From Death We Learn is a means of disseminating this important information to health professionals, health services and the general community.

The production serves to assure all stakeholders, especially the public, that unexplained and/or unexpected deaths are given serious consideration by the Department of Health, and that the recommendations arising from inquests are implemented as a means to prevent similar occurrences.

The publication is distributed to a wide range of health and allied health professionals across the state.

Dr Robyn Lawrence
EXECUTIVE DIRECTOR
INNOVATIONS AND HEALTH SERVICES REFORM