• The Communiqués

Clinical Communiqué Volume 9 Issue 2 June 2022

Download PDF:  Clinical Communiqué June 2022 Edition


In this edition

  • An anthology of patient safety expert commentaries

  • Editorial

  • Come so far but still so far to go

  • Ensuring we don’t fall short on safety – reflections of a health service researcher and clinician

  • Learning from inquiries and experience

  • What does the COVID-19 pandemic teach us about patient safety?

  • A coroner’s perspective on the pandemic

  • Death investigations and COVID-19

  • Patient safety and the role of regulators – current and future challenges

  • Twenty-year anniversaries: The Clinical Communiqué and Australia’s National Strategy Quality Use of Medicine

  • Some random observations from a systems thinker on patient safety

Welcome to the June 2022 edition of the Clinical Communiqué – a milestone moment for us that marks 20 years of work on this publication. In our inaugural edition, we told our readers that, ‘Our primary aim is to improve the awareness of clinicians and those in positions of governance about adverse events resulting from systems failures, and then to apply these lessons to their own institutions.’ Two decades and fifty editions later, we are proud to have stayed true to this course. Our name evolved from the Coronial Communiqué to the Clinical Communiqué, our designs modernised, and we became ever busier in our professional lives, but at the heart of it all we remain a small team who firmly believe that the process of sharing insights from coroners’ cases is both a powerful tool in improving patient safety, and a responsibility that we have the privilege of holding.


Much has changed in healthcare since we started, not least the immediacy of data. Where once clinical practice improvements were thought to take a decade to filter through and integrate into systems, now a significant advance can make sweeping changes overnight thanks to the power of the internet. However, the sheer scale of the available information can be overwhelming, and it is important not to get lost in big data or paralysed by the multitude of voices presenting opinion over expertise. There’s still a role for the oldest form of information transfer, that of narrative. That’s why the Clinical Communiqué continues to tell stories with a human focus and highlight the available expertise, to speak on behalf of those who are no longer here, and to ensure that their passing helps those in the future.


To honour this 20-year anniversary of the Clinical Communiqué, we have collated a remarkable collection of commentaries from experts in the fields of medicine, law, ethics, and clinical governance. Individuals who have contributed immensely to improvement work on patient safety over the past 20 years, and who have been integral in shaping the landscape of quality and safety in healthcare. We invited each of these renowned experts to share their insights on 20 years of quality in healthcare and patient safety - reflections on the past, lessons from the COVID-19 pandemic, and directions for the future, and we were delighted by their responses. In the last 20 years the scope of patient safety has expanded from individual activism by early adopters to an acknowledgement that safety principles should be embedded within every health system. General concepts of error and human factors have sharpened focus into sophisticated sub-specialty areas of problem identification and system improvement. The experts here have done more than most to define the topography of this new space, and we are fortunate to have them guide us up their very own mountains in this special edition of the Clinical Communiqué.