How Do Coroners' Findings in Australian Jurisdictions Apply to Health Care Practitioners within Safety-I and Safety-II Paradigms?

The modern-day coroner sits uniquely at the interface between health care provision, patient safety and the law, playing an important role in informing health care practices to improve patient safety. In the 21st century, the health care system has rapidly developed in the field of patient safety. First came the Safety-I approach of looking at what went wrong, then the Safety-II approach of understanding why things go right. The advent of Safety-II has flipped the way some health care organisations view their systems and it is now time for the coronial jurisdiction to do the same. By applying the Safety-I/Safety-II Model for coronial investigations into health care-related deaths, coroners can address both the positive and negative factors in each case and refine the lessons in their findings. A Safety-II approach allows their role to evolve even further, firmly entrenching their preventive ethos as they become architects of resilience for the health care system.