Pinching myself today, that I’m in Australia, spending dedicated time looking at learning from deaths. Feels somewhat surreal, a real privilege and a huge opportunity. I’ve deliberately kept my focus broad during this trip, trying to combine multiple perspectives, as much as it’s tempting (and possibly safer) to go deep on just one issue, I’ve tried to stay broad and big picture. I’m speaking with policy makers, academics, disabled people, bereaved relatives, advocacy organisations, legal professionals, those working in healthcare improvement and pretty much anyone else who feels that they have something to say about learning from deaths.

Today was focused on the coronial system. I’ve mixed feelings about the UK system, to badly paraphrase Henry Longfellow ‘when its good its very, very good and when its bad its horrid’. For a current, and horrific, example of a UK coroner getting things very wrong, closing the scope of an inquest into the death of a young woman, Colette McCulloch, check out her family’s crowdfunding for a judicial review and a Guardian article on her here.

I was very interested to learn more about the New South Wales system. Today I spent time talking with David Evenden a solicitor advocate at the Coronial Inquest Unit of NSW, Rebecca Scott Bray a criminologist from the University of Sydney, and Hugh Dillon a former Deputy State Coroner and magistrate and a 2014 Churchill Fellow.

The Coronial Inquest Unit provide free legal advice, assistance and representation to people at coronial inquests where the matter involves some ‘public interest’. Public interest is something of serious concern common to the public at large or a significant section of the public, such as a disadvantaged or marginalised group. One of the things that struck me as incredibly pertinent from my conversation with David was in relation to the variability of families experience and the absolutely key impact the police officer in charge can have. The police will conduct inquiries under the direction of the coroner, and will usually compile a family statement that covers background, history and context. David pointed out that the identity of the police officer makes quite a difference ‘if there is good communication, if the officer takes concerns on board, it can make such a difference, than if they don’t treat the family with respect and special care‘. A lot of this stuff comes back to being human, and respectful, and caring. To quote Shaun from My Life My Choice ‘It isn’t rocket science’.

This afternoon I met Rebecca and Hugh in a courtyard cafe at the University of Sydney. I felt deeply honoured to spend time in their company and pick their brains. In my own geeky way I’ve read a number of Hugh’s determinations such as this one into the death of Shona Hookey, a young intellectually disabled Aboriginal woman whose death he described as ‘the tragic conclusion to a cluster of mistakes and failures in systems intended to care for her’. He ends:

‘An inquest is one way our society shows respect for a person who has died a sudden, unexpected and perhaps preventable death. It is a way our society shows that individual lives are precious no matter who you are. And it is a way our society learns from tragic deaths. I hope that Mr and Mrs Hookey will accept the very sincere condolences and respects of the coronial team and the staff of the Coroners Court’.

Speaking to Hugh and Rebecca it was clear that they both held a strong belief and commitment to coronial processes answering questions for families, respecting the lives of those who have died, and perhaps most importantly identifying learning to prevent future deaths. They both clearly explained the value and role of research and evidence, as incorporated into coroner’s determinations, and also in developing the skills and expertise of those working in the field.

Rebecca has been working with the NSW State Coroner Michael Barnes and the NSW Coroner’s Office to determine why there has been an increase in the reporting of natural causes deaths, and what action can be taken to reduce them. This led to a discussion around the labelling of deaths, and the thorny issue of when a natural causes death converts into an unnatural occurrence that warrants further attention.

This really is key when people with intellectual disabilities die as we know from the Mazars Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015 that so many deaths are swept under the natural causes blanket:

Less than 1% of deaths in Learning Disability services were investigated as a CIR or SIRI and 0.3% of all deaths of Older People in Mental Health services were investigated as a SIRI.

As I strolled back to my digs from the university I saw a poster campaign about unlearning:

Words to end the day on, and live by, a very necessary rallying call for those interested in learning from deaths:

It is only be challenging the established, questioning the accepted and being brave enough to break down old rules, that we can write new ones.