November 28, 2005

Competent Death Reviews

Until the revelation that 713 child deaths had not been investigated, as they would have been if the Children's Commission had not been abolished, few would have questioned what goes on in the Coroners Service. Notwithstanding the drama around Da Vinci's Inquest, the BC Coroners Service has kept a low profile until heat was applied about 713 files on child deaths that were neglected in a Victoria warehouse.

The website for the Coroners Service says: "The Coroners Service of British Columbia is responsible for the inquiry/investigation of all unnatural, unexpected, unexplained or unattended deaths" (the definition of what a "natural" death is leaves a glaring loophole). Their findings not only assist in establishing a record for epidemiological purposes, but they also help grieving families reach closure; at least they did before Campbell's cuts hit the Coroners Service. The official coroner's report, called a judgment of inquiry (JOI), used to provide some insight behind the cold statistics - the history, the who, what and where aspects behind the death.

The B.C. Coroners Service "Guide to Completing the Judgement of Inquiry" (dated January 1, 2003 on the cover but December 19, 2002 on the pages) directs coroners to make one page Judgements as follows (bold and underline in the original):

Abbreviated Judgements are one reason some former coroners have formed the "Committee for Competent Death Review in BC" and have spoken out. Thanks to the Vancouver Sun and the work of the Official Opposition, a letter sent from the group to Solicitor General John Les has received prominent attention. In question period on November 24th, the NDP's critic for the Attorney General, Leonard Krog, described the group's letter to the Solicitor General when he said:

PubMed is the US National Library of Medicine's search service that provides access to over 11 million citations in the peer reviewed medical literature. Search on the terms "diagnostic error autopsy" and you'll find almost a thousand articles that document the difference between clinical (pre-death) and autopsy (after-death) diagnoses. Studies in every coroner of the world indicate error rates of 30% or more between what is diagnosed pre and post autopsy. Globally, the frequency of autopsies has decreased by about 50% in the past ten years; we don't know how great the reduction has been in BC. Study after study argues that autopsies are essential in order to educate physicians about their errors. A review of such studies in the US (Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA. 2003 Jun 4;289(21):2849-56.), revealed class I error rates (errors that affect survival) of 4.1% to 6.7%.

A study published in the Canadian Medical Association Journal in May 2004 discussed "adverse effects (AEs)" or medical errors and said: "By extrapolation, our results suggest that, in 2000, between 141,250 and 232,250 of 2.5 million similar admissions to acute care hospitals in Canada were associated with an AE and that 9,250 to 23,750 deaths from AEs could have been prevented."

Coroners are unlikely to investigate deaths because of adverse effects (medical errors) because they are likely to be deemed "natural". In the absence of autopsies, many deaths, whether natural or not, are likely to be misclassified, allowing mistakes to continue and trends to go undetected.

In question period on November 23rd, NDP Leader Carole James said:

Les responded with nonsense about professionals not compromising professionalism, apparently not anticipating the public disclosure of the letter from former coroners who formed the Committee for Competent Death Review in BC.