Coroner finds communication failures in healthcare deaths

Kathryn Booth, a Principal Lawyer in Medical Negligence at Maurice Blackburn, discusses a series of Victorian Coronial findings where communication breakdowns were found to be serious factors in healthcare deaths. Maurice Blackburn represented the families in each of these cases.

Kathryn Booth

Coroner blasts ‘outdated’ faxes

A Victorian Coroner has used a recent inquest finding to urge the phasing out of faxes to communicate medical test results as “a matter of priority”. In a finding handed down in May, Coroner Rosemary Carlin described faxes as “antiquated and unreliable”, and queried why they were still used at all in the medical profession.

Coroner Carlin’s comments were made in the inquest finding into the November 2015 death of Mettaloka Halwala from complications of chemotherapy. Less than a week before his death, Mr Halwala had undergone a routine PET scan to assess his response to chemotherapy treatment for Hodgkin’s lymphoma.

The scan revealed signs of potentially fatal lung toxicity from one of his chemotherapy drugs. The court heard these results were faxed to his treating haematologist, but they were not received before he had undergone a further course of chemotherapy that included the same drug associated with the lung toxicity. He was found dead four days later.

Coroner Carlin said while electronic distribution would not be a substitute for direct, usually oral, communication of medical test results, it was still “vastly superior” to faxes. In her finding, she recommended that the professional bodies work together on a set of standards for communicating imaging results.

The inquest finding into Mr Halwala is just one of a number of recent coronial findings in Victoria that have shown how poor communication in our healthcare system can have a negative impact on patient safety.

Hospital food caused fatal reaction

A coronial finding handed down in February this year, into the death of 13-year-old Louis Tate, focused on one Melbourne hospital’s poor food handling procedures for dealing with children with allergies.

In this case, Louis, who had allergies to cow’s milk, raw egg, peanuts and tree nuts, died in hospital after he was given breakfast that contained an unknown allergen, which set off an anaphylactic and anaesthetic reaction.

The court heard that the hospital’s policy at the time for communicating patient allergies involved documenting requirements on a whiteboard as well as oral communication between personal services assistants and nursing staff.

Two-hour delay leads to death

In the case of Lachlan Black, a toddler who died from a bacterial infection, the court heard that one of the doctors gave verbal orders for life-saving antibiotics, but there was a two-hour delay in their administration.

The coroner in the finding described the delay as “unacceptable”, and said it highlighted the dangers of verbal orders. She said it would be prudent for the hospital to implement a more targeted policy in relation to verbal orders.


These three recent Victorian inquests show that issues around communication are a common theme in medical deaths that are investigated by the Coroner’s Court. We are not looking for a standard of perfection. Health workers are humans, and errors can occur.

But what we need to see is better systems and procedures, as well as the use of the most up-to-date technology, as a safeguard to protect patients. These inquest findings also highlight the important role that coroners can play in improving public safety, including in our hospitals.

But it shouldn’t take a coronial inquest into a tragic death to tell us that a fax machine is outdated technology, or that a safe food handling procedure needs to be based on something more foolproof than an informal conversation between two people. Our hospitals need to be more proactive in improving communication and patient safety, instead of waiting for the next tragic death and a coroner’s recommendation before taking action.

Kathryn Booth
 who is based in Melbourne, is a Law Institute of Victoria Personal Injury Accredited Specialist and an Australian Institute of Company Directors Accredited Member. Kathryn practices exclusively in medical negligence claims on behalf of patients and their families. She is also one of three Maurice Blackburn lawyers listed by the prestigious Doyle’s Guide as a leading plaintiff medical negligence lawyer in Melbourne, and Best Lawyers has named her the top medical negligence lawyer in Australia. 

Kathryn established the firm’s medical negligence practice in Victoria in 1991, and was the head of the largest national plaintiff medical negligence team in Australia until 2018, when she stepped down from the role. She continues to practice solely in medical negligence claims and remains a trusted leader and expert in the medico-legal field. Contact Kathryn at