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Collaboration between the coroner and emergency physicians: efforts to improve outcomes from aortic dissection

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Following the recommendations in 2006 of the Victorian Parliament Law Reform Committee,1 the Coroners Act 1985 (Vic) was amended. The revised Coroners Act 2008 (Vic)2 included “prevention”, to explicitly recognise the coroner’s role in public health and safety. The Law Reform Committee report identified the need for a multidisciplinary team to assist coroners to fulfil their prevention mandate. The Coroners Prevention Unit (CPU), within the Coroners Court of Victoria (CCV), was established in 2008, comprising personnel from medicine, nursing, law, public health and social sciences. The CPU reviews cases to identify prevention opportunities and assess the adequacy of health care diagnosis and treatment proximate to death. The CCV annual report for 2011–12 shows that about 10% of deaths reported to the coroner were referred to the CPU, including those resulting from suicide, homicide and unintentional injury, and those that occurred in a health care setting. The CPU reviews statements from family, friends and witnesses, medical records, forensic reports, statements from clinicians and expert opinions, before preparing advice regarding identified risks and protective factors to the coroner, who may then make recommendations for government and non-government organisations with or without an inquest. The overriding aim is to identify prevention opportunities, particularly…

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