When silence threatens safety: lessons from the first Canberra Hospital neurosurgical inquiry

Despite widespread institutional and professional support, the recommendations of the Bristol Royal Infirmary Inquiry may be insufficient to reduce patient risk from impaired senior medical practitioners. Using the First Inquiry into Neurosurgical Services at the Canberra Hospital as a case study, this article argues that the Bristol-type recommendations--which emphasise reformulation of clinical governance structures, including early reporting of "sentinel events" and compulsory clinical audits--will be ineffective without a reformed institutional ethos that encourages open transparency and respect for those committed to such processes. Such reformulation may need to commence in medical education and involve new strategies including the use of portable digital technology to facilitate self-assessment of performance and immediate reporting of adverse incidents.     

The co-regulation of medical discipline: challenging medical peer review

The medical profession has always fiercely defended its right to self-regulation on the basis of peer review. However, in New South Wales, Australia, the profession has willingly surrendered these rights in favour of a disciplinary system known as co-regulation or collaborative regulation, under which disciplinary processes are shared with a "lay" body, the Health Care Complaints Commission. The system constitutes a unique situation in the history of medical regulation. This article examines the origin and operations of co-regulation and comes to the conclusion that its successful operation over the last decade raises questions about whether peer review is indispensable as the basis of medical regulation.     

Death due to unusual position of the body--an explanationfor the consequence of reduced venous reflux to the heart

The article describes the case of a 29-year-old woman who was found dead in her apartment on a bar stool with the body being maximally retroflected in the lumbar region, the head hanging down and the feet and hands barely touching the floor. On external inspection of the body the cuff-like distribution of hypostasis on the forearms and lower legs was consistent with the position in which the body was found. There were no signs of foreign intervention. At autopsy massive congestion was found in the internal organs as well as pulmonary and cerebral edema. In the ventral region of the lumbar intervertebral discs superficial hemorrhages were detected. The alcohol content was 3.40 per thousand in the blood and 4.43 per thousand in the urine. As the essential pathogenetic mechanisms responsible for death reduced venous reflux to the heart in combination with postural asphyxia and the influence of alcohol are discussed.     

Suicide with inert gases: addendum to Final Exit

Suicide by asphyxiation with a plastic bag placed over the head is a method that has been advocated by right-to-die groups. Recently, such groups have proposed the introduction of helium into the plastic bag as a means of hastening death. Helium is readily available at toy stores, where it is sold in tanks for balloon inflation. It produces asphyxiation by the exclusion of oxygen in enclosed spaces. We report 7 fatalities throughout an 18-month period involving plastic bag suffocation in conjunction with helium use. These fatalities coincide with publication of an update to a popular right-to-die text in which this method is described. Although right-to-die literature was absent from all scenes, this method was not previously observed in our jurisdiction, and the deaths likely reflect exposure to this information. Because of analytical difficulties in testing for helium in biologic specimens, death certification rests on scene investigation.     

Prothrombin G20210A mutation and sudden death

The authors present a case of sudden death in a previously healthy 36-year-old male. At autopsy there were bilateral pulmonary thromboemboli and right ventricular dilatation. Histologic findings in the lungs included recanalized, old thrombi and evidence of pulmonary hypertension. Genetic analysis for hereditary risk factors was heterozygous positive for the prothrombin G20210A mutation. Implications of this finding, its history and the diagnostic technique shall be discussed. The authors recommend that all cases of deep venous thromboses and pulmonary thromboemboli lacking known risk factors be evaluated for newly described genetic variations associated with an increased risk for venous thrombosis.     

Is the doctor in? The evolving role of organized medicine in health policy

Until recently, physicians were viewed as the dominant player in health policy. Now, however, they compete with many other effective interest groups. This article analyzes this changing role, and specifically how organized medicine has changed its approach to influencing health policy. The essay begins with a review of the reasons for the growth and subsequent decline of physicians' influence. This is followed by a case study of physician payment reform under Medicare, which illustrates the ways in which organized medicine chooses when and when not to cooperate with government. The article concludes with a discussion of where physicians are likely to continue to be influential in future health policy reform. Three such areas are noted: payment policy, quality and clinical innovation, and medical education and training.