The Communiqués Podcasts

by The Communiques

Welcome to The Communiqués Podcasts. Our podcasts present cases of preventable deaths that occur in health and aged care settings. We explore 1) What happened? 2) Why did it happen? 3) What action can we take to prevent it from happening again? The cases are the accounts from completed medico-legal death investigations of the Coroners Courts, and our team of senior medical and nursing practitioners present this information to m ...   ...  Read more

Podcast episodes

  • Season 5

  • CC Podcast Episode #12: Extubation Crisis

    CC Podcast Episode #12: Extubation Crisis

    In this episode we feature two cases of worsening upper airway swelling leading to fatal airway obstruction following routine extubation of patients after surgery. Despite many advances in airway management, extubation-related incidents have not reduced. The cases highlight the actions leading to the loss of airway protection, a failure to recognise the severity of the situation, and an inability to salvage the situation. We also welcome a new narrator Ashleigh Redmond who is a practising registered nurse and actor. This is Episode Twelve of our podcast series and features material from our June 2023 print edition of the Clinical Communiqué. Episode Contents 01:48 Editorial by Associate Professor Nicola Cunningham 06:15 Case #1: A fatal toothache by Suzanne Doherty 19:54 Case #2: Pulling teeth and tubes - a cautionary tale by Dr Jack D'Arcy 36:28 Expert Commentary by Dr Louise Ellard: Extubation: An assessment of risk and strategy

  • RACC Podcast Episode 16: Wheelchair Fall

    RACC Podcast Episode 16: Wheelchair Fall

    This podcast episode presents the results of the investigation into the premature death of a resident who had a fall from a runaway wheelchair. The three commentaries draw on clinical and research experts to address how to balance improving mobility with a wheelchair while mitigating potential harm. We also welcome a new narrator Ashleigh Redmond who is a practising registered nurse and actor.  This is Episode Sixteen of our podcast series and features material from our May 2023 print edition of the Residential Aged Care Communiqué. Episode Contents 01:22 Editorial 05:15 Case A fatal downhill slope 15:11 Commentary: Falls of wheelchair users: what do we know? 19:18 Commentary: Call an OT 26:00 Commentary: Looking deeper 27:49 Reflections of senior nurses

  • Season 4

  • Residential Aged Care Communiqué Episode #15: Unexplained absence

    Residential Aged Care Communiqué Episode #15: Unexplained absence

    Escaping, absconding, unexplained absences lead to death. The investigation into a resident’s unexplained absence determined the cause of death as hypothermia secondary to becoming lost in surrounding bushlands. The inquest findings are presented along with expert commentary around how to prevent unexplained absences. This is Episode Fifteen of our podcast series and features material from our February 2023 print edition of the Residential Aged Care Communiqué. Episode Contents 01:33 Editorial 04:05 Case Cold, wet, in the dark, and alone 18:42 Commentary: Preventing unexplained absences 25:55 What do senior nurses think?

  • Clinical Communiqué Episode #11: First Nations

    Clinical Communiqué Episode #11: First Nations

    In partnership with First Nations Peoples from clinical, education, design, and consumer advocacy backgrounds, this critical edition of the Clinical Communique presents two coroners' cases where a lack of cultural safety in the health care system led to preventable and tragic consequences. Special thanks to Mr Olli Wynyard Gonfond who narrated this episode, and Dr Jordana Stanford for her guest apperance. This is Episode Eleven of our podcast series and features material from our March 2023 print edition of the Clinical Communiqué. Episode Contents 01:07 Editorial by Associate Professor Nicola Cunningham 07:46 Guest Editorial by Ms Belinda Gibb 18:33 Case #1: A culture of care by Dr Glenn Harrison 28:42 Case #2: Seen but not heard by Dr Jordana Stanford 40:11 Expert Commentary by Dr Olli Wynyard Gonfond: Developing cultural safety behaviours and capabilities in health care 46:41 Expert Commentary by Ms Jacqui Gibson: Why cultural safety improves patient safety

  • Future Leaders Communiqué Episode #11: Locums

    Future Leaders Communiqué Episode #11: Locums

    Welcome to Episode #11 of the Future Leaders Communiqué podcast. In this episode, we present a thought-provoking summary of the events leading to the tragic death of JL, a 69-year-old woman recovering from an elective neurosurgical operation. We reflect on the challenges faced by junior doctors engaging in locum work and the chain of communication in medical imaging reports. Episode Contents 01:05 Guest Editorial by Dr Tony Pham 04:22 Editorial by Dr Brendan Morrissey 07:38 Case: An obstruction in an unfamiliar place by Dr Tony Pham 20:07 Expert Commentary #1: Technological solutions: A remedy for human error? By Ms Nicole Mair 26:17 Expert Commentary #2: Ready, Set, Go: safe orientation of locum doctors by Dr Brendan Morrissey 32:41 Comments from our peers