Psychiatric Essentials for International Medical Graduates - NBTA

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					 Bulk Tanker Emergency
Response-sharing lessons
and improving outcomes
              Case Law –
       learning from the Coroner
                  Dr Jane Hendtlass
 B.Sc.(Hons.), LL.B.(Hons.), Ph.D., A.R.A.C.I., F.A.I.C.D., A.I.M.M.
                      6 September 2012

n   The Role of the Coroner
n   Relevant Legislation
n   Coronial Investigation
n   Tankers in the Coroners Court
n   Cause of the collisions resulting in driver
n   Comments and Recommendations
n   Summary
Role of a Coroner
The coronial system of Victoria plays an
  important role in Victorian society. That
  role involves the independent investigation
  of deaths for the purpose of finding the
  causes of those deaths and to contribute to
  the reduction of the number of preventable
  deaths and the promotion of public health
  and safety and the administration of justice.
  Coroners Act 2008
Relevant Legislation
n All  coroners’ work is directed by
    legislation including:
Ø   Coroners Act 2008
Ø   Victorian Institute of Forensic Medicine Act
Ø   Police Regulation Act 1958
Ø   Births Deaths & Marriages Registration Act
Ø   Human Tissue Act 1982
           Coroners Act 2008
n   Creates the Coroners Court of Victoria
    as an inquisitorial jurisdiction
n   Provides for appointment of coroners
Ø   Lawyers with five years experience
n   Includes 8 full time coroners:
Ø   State Coroner and Deputy State Coroner
Ø   Direct appointments
Ø   Magistrates allocated in consultation with the Chief Magistrate
§   Magistrates in regions who also sit as
       Victorian Institute of
    Forensic Medicine Act 1985
n   The functions of the Institute include:
o   to provide facilities and staff for the conduct of
    examinations in relation to deaths investigated
    under the Coroners Act 2008.
o   to provide reports to coroners about the medical
    causes of deaths and the findings and results of
    investigations and examinations.
§   to host the National Coroners Information Service
Police Regulation Act 1958
n   Assumes that police investigators
    provide corners with crucial specialist
    assistance in that it:
o   Requires police to assist the Coroner whenever a
    coroner so requests.
o   Provides for police allocation to the Police Coronial
    Support Unit.
o   Enables police assistance in Inquests.
Human Tissue Act 1982
n   The coronial role takes precedence
    over retrieval of human tissue for
    transplant or research:
o   A coroner must also give consent to taking of tissue from
    deceased donors if the death is or may be a reportable death.
o   Authority under the Coroners Act 2008 to remove tissue is,
    subject to any order to the contrary by a coroner, authority
    for the use, for therapeutic, medical or scientific purposes, of
    tissue removed from the body of the deceased person for the
    purpose of the post-mortem examination.

n   Role of a coroner is to investigate reportable
n   Doctors, forensic pathologists, police, the
    Registrar of Births Deaths & Marriages and
    the general public must assist a coroner
    investigating a reportable death
n   A coroner must authorise removal of tissue
    from donor if the death is a reportable
     Coronial Investigation

n   The Coroners Act 2008 requires a Coroner to
    investigate all reportable deaths to determine
    where possible:
o   identity,
o   time and place of death,
o   cause of death.
§ Unless the death is from ‘natural causes’ or further
    investigation is not in the public interest, the
    Coroner must also determine:
o   how the death occurred.
National Coronial
Information Service
n   All deaths reported to coroners in Australia
    & New Zealand
o   Not all the same selection criteria
o   Coding varies
n   Includes autopsy and toxicology reports,
    Form 83s, Findings, Recommendations
n   Board includes all State Coroners and Chief
n   Access is by consent of the Board
    Tankers in the Coroners
n   104 deaths involving “tankers”
    reported to coroners in Australia since
    2001 or about 10 deaths a year

n   3 multiple death incidents including
    the Pettet family in Koo Wee Rup in
n   26 tanker drivers or occupants
Tanker Occupants in the
Coroners Court
The 26 tanker drivers or occupants
n 15 tanker drivers in Victoria

n 6 tanker drivers interstate

n 4 tanker passengers

n 1 tanker passengers interstate
Tanker drivers in the
Coroners Court
The cause of death for the 31 tanker drivers
n 5 injuries sustained in the incident

n 9 natural causes including: cardiac
  condition, undiagnosed brain tumor, aortic
n 2 suicide when not in truck (does not include suicide by
    other road users)

n   4 drugs
Cause of the collisions resulting
in tanker driver deaths
n   Maintenance:
o   Break in the diesel line
o   Non standard parts
n   Driving:
o   7 roll over consistent with
o   6 speed in the circumstances
n   2 no seat belt
n   1 possible fatigue
n   Fire following roll over following cardiac event
Cause of the collisions resulting
in other road user deaths
n   Tanker driver
o   2 fail to stop: 1 explained by hypoglycaemia
n   Passenger
o   In sleeper compartment without restraint
o   Fell out of truck
n   Other road user
o   5 fail to stop or give way at intersection
o   9 lost control or keep proper look out
o   5 possible suicide
o   3 pedestrian on road
o   1 pedestrian behind tanker
Comments and
n   A coroner may make recommendations to any
    Minister, public statutory authority or entity on any
    matter connected with a death which the coroner
    has investigated, including recommendations
    relating to public health and safety or the
    administration of justice.
n   If a public statutory authority or entity receives
    recommendations made by the coroner, the public
    statutory authority or entity must provide a written
    response, not later than 3 months after the date of
    receipt of the recommendations. Coroners Act 2008
n   All employers in the transport industry
    should be encouraged to be involved
    in the “Health Break” program and
    insuring, as far as is practicable and
    appropriate, that their drivers
    participate in the checks and any
    follow-up examinations and treatment:
    findings in the death of Robin Alan Scott & Rodney Thomas Gesler
Recommendations 2
I would recommend that publicity be
  given to warning of the dangers of
  fitting after market parts unless they
  possess the same or equivalent
  properties of the part they are
1.   Coroners only see incidents in which
     someone dies.
2.   Coroners investigate tanker incidents with
     the assistance of the forensic pathologist,
     the police and other experts.
3.   There are about 10 deaths per year arising
     from tanker incidents in Australia.
4.   About 3 tanker drivers die a year.
5.   Half of all driver deaths are from natural
6.   All roll over deaths occurred because
     drivers lost control during a health related
     event, mainly cardiac disease or drug-
     related speed.

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