Purpose and Process of a Coronal Inquest for Unusual Deaths
Question:
Discuss about the Coronial Process And Inquests.
A coronial inquest is a proceeding held to establish the reason of death and the situation under which an unusual death occurs. It is conducted by a judicial officer who is termed as a coroner. It’s a public proceeding that aims to find answers to reportable fatalities and prevent future similar incidences. Before the inquest, the coroner can request autopsy reports to determine the precise reason of death in cases where the cause cannot be explained from the history given and the police report from the scene. Witnesses usually are called upon to give evidence. Functions of an inquest are to provide suggestions to prevent similar deaths in the future and determine any suspicions of a criminal offense. This case study narrows down on coronial inquests about children drowning in swimming pools. The hearings aim to determine the cause of death whether it is drowning or if there were any suspicions, provide vivid evidence and police reports then come to a conclusion stating the recommendations to avoid any future child drowning incidences.
In the case study about children drowning in pools, the coronial process has been applied to the latter end. According to the Rockhampton inquest on a 10-year-old child died from drowning in a pool. The case was reported and investigated upon. During the investigation, the coroner decided to conduct an inquest. In the hearing, witnesses were called upon to give an account of the happenings of the day to as evidence. All events were investigated to eliminate suspicion of anyone being involved in the death. An autopsy report wasn’t done since the cause of death was evident (Coroners Act s7). The child was under supervision by family and was warned against the danger spots. After collection and hearing of evidence, risks assessment was done, and recommendations were made to prevent similar deaths occurring in the future. Some families request for an inquest in case they want to enlighten other families and prevent the occurrence of similar incidence. According to Sebastian’s inquest, the parents and coroner demanded a hearing to know the cause and circumstance of death, the risk factors that precipitated and the future changes towards promoting safety. Risk factors of the location of the pool were assessed and recommendations made in line with the colonial process. In the Jean-Marie inquest, investigations were carried out after the case was reported following an autopsy. A coronial inquest was carried out to discover anything suspicious occurred surrounding the situation. Witnesses gave the evidence, and a police report examining the scene and the causative factors were identified. Areas of weakness were spoken out and recommendations made.
The common factors between the three inquests based on causes of death are; the child was not a competent swimmer, not adequately supervised and had a disability of being unable to understand and follow instructions carefully. The contributing factors of the incident include; ignorance of the child, failure of the owner of the pool to assess the risks present, the situation of the inflatables and due to incompetent and inadequate staff to educate the clients and supervise the children within. (Rockhampton inquest). Other causes of death are due to negligence (Sebastian inquest). The death could have been prevented if there was a fence obscuring the child from accessing the pool. The father of the child in the Jean-Marie inquest fell asleep and took his eyes off the child. This was on top of the presence of a faulty gate that could not close completely. This act of negligence caused the death of the child. Another common cause of death is when the parent or guardian fails in the responsibility of protecting the child. This was contributed when the guardian transfers responsibility to strangers and forgets or in the case of Brisbane inquest where the parent is suspected to have been on drugs the previous night. In the outcomes, the children died unusual and sudden deaths that could have been prevented if the responsible adults performed their roles (Weber, & Pickering, 2014). The hearings conducted identified the weakness that caused the incidences, some of which could be prevented and some needed recommendations to be implemented to avoid similar happenings. In the outcome, the family members were consoled and explained to the findings of the investigations on the causes of the deaths and what went wrong (coroners act s46).
Common Contributing Factors and Causes of Deaths
Public health is a field that deals with prevention of occurrence of disease, improving quality of life and lengthening life through assessing of risk factors available in the society and rectifying them. The above deaths could have been prevented from my public health perspective. By applying the risk prevention policy, the faulty inflatables could be tasted and rectified before being used and the malfunction identified and client education given out on how to use them, the risks involved and the degree of supervision required for children. The staff working at the pool with no qualifications could be trained first on how to supervise and protect children. According to public health perspective, the management should equip the staff with knowledge of life-saving techniques, digital monitoring around the pool and the expertise on the use of devices within. Children with disabilities whether minimal or those under medical treatment or very young children should not be left alone (Franklin, Pearn & Peden, 2017). They should be enrolled in groups where they can be taken care of by specialists who understand their situation. Public health incorporates homestead risk avoidance such as ensuring critical point such as pools are appropriately fenced out of reach of children. Irresponsible parents who are on drugs should not be allowed to raise children on their own, and this could prevent the deaths and future incidences (Haynes, Coates, van den Honert, Gissing, Bird, de Oliveira, … & Radford, 2017). Recreational places such as pools should be assessed periodically for any risks, mostly before summers. The pools in homestead should also be monitored to ensure they are out of reach of unsupervised children and the apparatus are not faulty.
Coronial process contributes largely to public health practice due to the recommendations that are made during the inquest. Introduction of life-saving societies where society receives education on life-saving procedures of how to save drowning people, the swim and keep teachings and provide resuscitation equipment to the firms this promotes first cause of action in cases of emergency and can preserve life in the society (Coroners Act s45). Creating safety alerts contributes to public health as the population will be aware of the risks at hand (Bugeja, Ibrahim, Ferrah, Murphy, Willoughby & Ranson, 2016). This alert comes after a risk assessment of the environment by carrying out periodic inspections and identifying the dangerous areas hence enabling people to adjust and be careful. Safety measures should be done and evaluation of the condition of pools before summer holidays before client’s report. The pool builder certifiers should be followed and ensure proper fencing and gates are established instead of leaving the responsibility to the owners as in the Jean-Marie inquest. There should be establishment of entry and exit rules (Bugeja et al., 2016). Children should not enter without responsible guardians, and they should be monitored through the stay the child was not monitored in the Rockhampton inquest hence the death.
In the contribution to public health, there should be implementation of recommendations like the establishment of effective monitoring techniques where all children can be monitored from one point by use of technology such as digital photographs of what’s happening hence ensuring they are safe. Enroll children and people who don’t have swimming skills for practice to avoid pool accidents as they can swim out (Bugeja, & Dwyer, 2016). The staff employed must have qualifications and expertise as far as safety is concerned. The team should also be adequate in number depending on the size of the pool, and the population can hold A person or organization should be held responsible in case issues of negligence occurs and they shall face penalties to act as an example to the society in general. Recommendation on proper communication during an investigation. Witnesses should give a clear and vivid explanation of the incidence so as appropriate strategies may be put in place to avoid future happenings thus preserving human health. Recommendation to the council to perform tasks such as pool fencing to promote the safety of the public at large.
Recommendations Made During the Hearings
Public health contributes significantly to coronial process in that it helps the law to achieve its goals. Public health perspective ensures the recommendations of the coronial process are put into place. The perspective has its aims that strengthen the laws (Sutherland, Kemp, Bugeja, Sewell, Pirkis, & Studdert, 2014). The standpoint of ensuring life is preserved, and risks are eliminated it contributes to fastening the policies in place on protection and rights of the society. A policy is a stated suggestion, but public health focuses on the strategies put in place and the manpower to ensure safety and prevention from unexplainable deaths such as in the Jean-Marie inquest. Evidence-based public health helps to expand research in strategies for preventing unusual deaths (Haebich, 2015). Preventive measures are conducted in the society to assess the general condition and the safety of everyone in general avoiding deaths like in the Sebastian inquest. Individuals are enlightened on the safety measures and the rights and rules of practice hence they should be able to report any occurrences that are outside the code of conduct. The happenings in the Sebastian inquest, Jean-Marie and Rockhampton inquests are in line with the policies of public health and safety (Abawi, & Brady, 2017). Ensuring life of people is preserved and those that fail to attend to it face the consequences. Policies are to promote long-term health effects with low cost and providing positive outcome of disease hence prolonging life. Its rationale is to improve the general health of the society by the necessary amendments and implement monitoring strategies preventing unusual deaths and fires in the nation at large.
Conclusion
Colonial process helps the society in general to identify the risks in place and ways of curbing them. on the other side, the recommendations that arise during a colonial inquest are implemented hence promoting health of the public in general. This focuses on the objectives of health of improving quality of life and prolonging life. The pieces of evidence collected during the investigation process identifies the individuals who are indirectly or directly linked to the incidence and ensure necessary actions are taken upon them. It also systematically helps families to get over stressful situations by explaining the cause of unusual death or fires. It helps them understand and recover from the trauma by explaining the origin, circumstance and by alleviating the suspicions that someone was involved.
References
Abawi, Z., & Brady, J. (2017). Decolonizing Indigenous Educational Policies. Emerging Perspectives: Interdisciplinary Graduate Research in Education and Psychology, 1(1), 20-30.
Bugeja, L., & Dwyer, J. (2016). Enabling public health and safety through the coroners’ death investigation system: The principles and practice of the coroner’s prevention unit. Grief Matters: The Australian Journal of Grief and Bereavement, 19(2), 47.
Bugeja, L., Ibrahim, J. E., Ferrah, N., Murphy, B., Willoughby, M., & Ranson, D. (2016). The utility of medico-legal databases for public health research: a systematic review of peer-reviewed publications using the National Coronial Information System. Health research policy and systems, 14(1), 28.
Bugeja, L., Woolford, M. H., Willoughby, M., Ranson, D., & Ibrahim, J. E. (2017). Frequency and nature of coroners’ recommendations from injury-related deaths among nursing home residents: a retrospective national cross-sectional study. Injury prevention, injuryprev-2017.
Coroners Act 2009 s45(2)
Coroners act 2009 s46(1)
Coroners Act 2009 s7(3)
Franklin, R. C., Pearn, J. H., & Peden, A. E. (2017). Drowning fatalities in childhood: the role of pre-existing medical conditions. Archives of disease in childhood, archdischild-2017.
Haebich, A. (2015). Somewhere between fiction and non-fiction New approaches to writing crime histories. TEXT, 28.
Haynes, K., Coates, L., van den Honert, R., Gissing, A., Bird, D., de Oliveira, F. D., … & Radford, D. (2017). Exploring the circumstances surrounding flood fatalities in Australia—1900–2015 and the implications for policy and practice. Environmental Science & Policy, 76, 165-176.
Inquest into the Death of Jean-Marie JeremieYannick Zaza [2009] Office of the State Coroner (Queensland) 16/08
Inquest into the Death of a child at Rockhampton [2010] Office of the State Coroner (Queensland) 2007/145
Inquest into the Death of Sebastien Yeomans [2015] Coroners Court of New South Wales 2012/157613
Sutherland, G., Kemp, C., Bugeja, L., Sewell, G., Pirkis, J., & Studdert, D. M. (2014). What happens to coroners’ recommendations for improving public health and safety? Organisational responses under a mandatory response regime in Victoria, Australia. BMC public health, 14(1), 732.
Wallis, B. A., Watt, K., Franklin, R. C., Nixon, J. W., & Kimble, R. M. (2015). Where children and adolescents drown in Queensland: a population-based study. BMJ open, 5(11), e008959.
Weber, L., & Pickering, S. (2014). Counting and Accounting for Deaths of Asylum Seekers en Route to Australia.
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