Coroners Act Response to the Coronial Findings in the matter of Ms Irene Magriplis dated 21 September 2017
Tabled paper 426
Tabled papers for 13th Assembly 2016 - 2020; Tabled papers; ParliamentNT
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1 . Prepared due to the death of Irene Magriplis; and 2. Submitted to I-Iealthscope head office in relation to her death." 187. There was no response to that request. The General Manager was asked about that when giving evidence. She provided a 'Risktnan' report and confirmed that was the only document fitting the request. There was no Root Cause Analysis. There was no Critical Systems Review. 188. I asked her why that was so when the policy clearly defined the deterioration and death of Mrs Magriplis as a sentinel event. She initially said it was because, "Mrs Magriplis did not die in the Darwin Private Hospital". 35 When I pointed out that the place of death was not part of the definition, I was told it was because Healthscope did not classify the death of Mrs Magriplis as a sentinel event. Dr Seiler provided the following evidence: "The risk man that we submitted is reviewed by Healthscope and it was not defined as a sentinel event"~ Q. I'm sorry, who does the defining? A. The National Risk Quality Manager. Q. And why does the National Risk Quality Manager do the defining? A. It's their job."36 189. It was disappointing that Healthscope was willing to allege that they conduct reviews into all sentinel events in the very case they did not. 190. As I have often said, the Coroner's Court is not a court of perfection. Most people at some time fall into error. But having recognised the error it is important that it not be repeated. To ensure that, there must be a review performed seeking to understand why the systems permitted the errors and where improvements can be made. 35 Transcript pp 1 7 8, 1 7 9 36 Transcript p.l 79
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