• The Communiqués

Volume 8, Issue 1, Mar 2013

Download PDF: RAC Communique 2013-03


Welcome to the first issue of 2013. In this issue we present a fascinating case of a resident who dies within an hour of admission to RACS. It captures a wide range of professional, organisational, clinical, pathology and legal matters.


The case should prompt vigorous debate amongst your friends and colleagues who are at the point of care and those responsible for managing and operating a RACS.


To cover the breadth of topics we expanded to six pages to provide three expert commentaries. A/Prof David Ranson gives a view from a senior forensic pathologist about the cause of death and evidence. Ms Marrianne Beaty describes the benefits and limitations of the clinical incident investigation technique, root cause analysis. Dr Cathy Balding’s comments are on the importance of governance.


Finally, as promised, we have our part III on using statistics. This time we discuss what factors to consider when choosing an area of clinical risk to measure and improve.

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