These referrals will join six deaths previously referred to the Coroner, meaning a total of 29 cases will be assessed following the examination of an additional 65 cases. 

The Department of Health is committed to providing the families with the information and support that they require and the Department is in the process of contacting affected families. The Department will progress with an open disclosure process, if the families accept this offer.

The Panel has confirmed that it has not observed any practices or evidence that there is a systemic issue.

The Panel has also advised it has been provided with sufficient evidence from staff that both junior and senior clinical staff are aware of the relevant policies and are adhering to them.

The Panel has also made a series of recommendations that focus on enhancement of documentation, protocols and systems that will strengthen the reporting of deaths across the Department.

The Department of Health accept the recommendations and will immediately begin the process of ensuring the relevant actions are taken, including notifying the Registrar of Births, Deaths and Marriages of the anomalies that the panel found.

The Department will also refer the report to Tasmania Police, the Integrity Commission and AHPRA for assessment. The additional information will also be provided to AHPRA. 

The Panel has undertaken a significant amount of work and I thank them for their dedication and diligence to the review. 

On behalf of the Department of Health, I apologise to the families and friends of those impacted. 

The Department acknowledges the distress these findings may cause, and we will actively engage with, and support, families through the open disclosure process. The Department will provide a dedicated contact for families affected. 

The Department again reiterates that anyone who has concerns about the care that they or their loved ones receive in our facilities can contact the Department of Health in the following ways, with all complaints and concerns treated very seriously and appropriately investigated:

• Through individual hospitals and health services. Health care teams can provide you with information about how you can register a complaint or concern.
• Through the Department of Health website at Reporting Concerns of Inappropriate Behaviour Form (health.tas.gov.au), either anonymously or with your details. This information comes directly to the Department of Health’s Office of the Secretary – independent of the hospital or health service – and is confidentially recorded for review.
• For more information on how to report a complaint, visit www.health.tas.gov.au
• To download and read the full copy of the Report, visit: Reportable deaths review | Tasmanian Department of Health