When come to the period where there is a change over of healthcare professionals in the hospital, the question, “what is the difference between Coroner’s Case and Sentinel Event?” has always been asked.

 

It is crucial for nurses to understand the concepts so that they can be better prepared with all the necessary paper works to handle the administrative work involved. It also help us to understand our rights to report a Sentinel event or to prevent such event to happen, when someone is not doing the right thing.

 

In Singapore, under the Criminal Procedure Code Cap 68, all cases meeting the following criteria should be referred to the Coroner and the police must be notified.

 

Criteria for Coroner’s Case

 

Death due to known, or likely, to have been due to, of the consequence of, any violent or unnatural event of cases, such as:

  • Homicide or suicide
  • Any accidents, including drowning
  • Asphyxia and choking, including aspiration pneumonia
  • Electrocution and lighting strike
  • Burns and scalds
  • Drug overdose and poisoning
  • Infection following injury/unnatural event
  • Any occupational diseases
  • Want, neglect or exposure

 

Death that occurred during, or at any time after, which may be deemed in any way, to have been caused, or contributed by:

  • Any operation or invasive procedure
  • Use of therapeutic substances (Western drugs, TCM, alternative cures)
  • Medical devices
  • Blood or blood products
  • Any medical intervention

 

Death occurring whilst in statutory care:

  • Death of persons in police custody, prisoners, or destitute persons detained involuntarily
  • Brought in dead when cause of death is unknown
  • Unidentified person
  • Death under suspicious circumstances

 

A sentinel event has to be reported to the Clinical Services Department immediately, as it has to be notified to Ministry Of Health (MOH) within 7 calendar days. Any medical, nursing and paramedical staff can report a sentinel event. All deaths that are sentinel events should be made a Coroner’s Case.

 

Criteria for Sentinel Event

 

An unexpected occurrence involving death OR major permanent loss of function / major injury, AND that is associated with the treatment, lack of treatment, or delay in treatment of the patient’s illness and underlying condition :

 

  • An occurrence shall be categorized as follows:
  • Blood transfusion
  • Childbirth / Pregnancy
  • Inpatient suicide
  • Medication usage
  • Surgical / procedure complications:
    1. Ward based (e.g. chest tube insertion, pleural biopsy and Haemodialysis, etc.)
    2. Non-ward based (e.g. surgery done in operating theatre, angiography and CT-guided biopsy, etc.)

 

·        Others, for example

1.      fall

2.      choking

3.      use of restraints

4.      medical equipment, etc

 

The MOH has defined that the following specific cases are also to be categorized under sentinel event when:

  • Retained instrument or material after procedure
  • Wrong type of procedure or surgery
  • Wrong site procedure or surgery
  • Wrong patient procedure or surgery

I sincerely hope that the above information will be useful for the nurses, especially the newbies in the wards. With better understanding of the concepts will give them an upper hand advantage to when handling such cases confidently. I also encourage them to continue to learn and excel.