Wednesday, December 7, 2016

From: Date: Wed, Dec 7, 2016 at 12:12 PM Subject: RE: Fatality reports, adverse events and tracking recommendations and post adverse event reporting (AC425296) To: **********This is an automatically generated email, please do not reply to this email. ********** Thank you for asking a question or sharing your thoughts with the Government of Alberta. We try to respond to all questions within 3 working days. If you need to visit us again, please visit Alberta.ca Stay in touch Sign up for Alberta News Participate in a public consultation This site is frequently updated to provide you with important information about Alberta programs and services. It's also an opportunity for you to provide your government with feedback on the issues that concern you. Please visit our site again soon to read an article, or send a comment. Internet: Alberta.ca (AC425296) Your message was -- Fatality reports, adverse events and tracking recommendations and post adverse event reporting In a recent response from Alberta Justice I was told that individual GOA departments are responsible for implementation of fatality report recommendations. Please refer to this e-mail: ---------- Forwarded message ---------- From: Ministry of Justice Date: Tue, Nov 8, 2016 at 10:42 AM Subject: Re: Fatality Reports To:> Cc: Office of the Premier PCU 94078 Dear Ms. Ali: The Honourable Rachel Notley, Premier of Alberta, has forwarded me a copy of your follow-up to Ms. Jennifer Fuchinsky’s email response to you regarding removal of fatality reports from the government website. Premier Rachel Notley has reviewed your correspondence and has asked that I respond on her behalf in my role as Minister of Alberta Justice and Solicitor General. In an email from Jennifer Fuchinsky’s dated October 5, 2016, you were advised that in order to keep the Justice and Solicitor General website up-to-date and to provide an optimum user experience, we review the site’s information for how recent it is. Due to the volume of fatality inquiry reports, we only keep those from the last two years on our website. You were also advised that there was a project in the works to eventually place all fatality inquiry reports online. I am pleased to inform you that this project is now underway and reports pre-dating those on the Justice and Solicitor General website will be uploaded to the Open Government website on an ongoing basis. You can access these reports at the following web address:http://open.alberta.ca/dataset? tags=public+fatality+inquiries&sort=createdate+asc Fatality inquiry reports are distributed to the parties involved in the inquiry and to those who may be impacted by recommendations. The Government of Alberta does not follow up on recommendations as it is these parties who have the authority and responsibility to determine whether recommendations are appropriate to be implemented. When recommendations are directed at a ministry of the Government of Alberta it is the sole responsibility of that ministry to review and determine how or whether it is feasible to implement recommendations in whole, or in part. Thank you for writing to share your concerns with our government and I hope that this information is helpful. Sincerely, Kathleen Ganley Minister of Justice and Solicitor General cc: Honourable Rachel Notley Premier of Alberta This email and any files transmitted with it are confidential and intended solely for the use of the individual or entity to whom they are addressed. If you have received this email in error please notify the system manager. This message contains confidential information and is intended only for the individual named. If you are not the named addressee you should not disseminate, distribute or copy this e-mail. My questions are as follows: 1) Is there a specific section of GOA departments such as Alberta Health and Human Services that review the recommendations of fatality reports? 2) Is there a job order assigned to each recommendation for tracking? 3) Is there longitudinal follow up of each recommendation by each department? 4) When repeated fatality reports issue the same recommendation who is penalized for failures of the GOA departments to successfully implement recommendations? 5) Does anyone in any GOA department ever receive disciplinary action for failures in child welfare or in continuing care? 6) Is there any GOA department other than Alberta Justice reviewing these fatality reports? I assume here that Alberta Justice staff are reviewing these reports. Please correct me if I am wrong. 7) Is it not ultimately the responsibility of the Premier's office to ensure that all GOA departments under the mandate of the Premier's office implement fatality report recommendations? 8) Does any one do any sort of review of all these fatality reports over time? Or do citizens have to do the work of government to determine if the same problems are repeating and no action is being taken? 9) May I at this time also ask why we cannot have the fatality reports stay on the Alberta Justice website. In my opinion this would be sensible and I don't think that having all of them on the site will be a problem since the government has unlimited storage capacity. So why not leave them there? 10) From an e-mail I received about the Open Government portal I was told that there will be ten years of fatality reports uploaded. Can you let me know the total number of years for which the GOA has fatality reports? I was told that ten years of reports will be uploaded by January 2017. Have they only been done for 10 years? This seems surprising to me. 11) How many fatality reports in total are there? 12) Why aren't medical examiner reports filed by Alberta Justice in a similar database? 13) The federal government indicates a wide variation between provinces in medical examiner investigations. What percentage of deaths in Alberta undergo medical examiner review? http://www.statcan.gc.ca/pub/82-214-x/82-214-x2012001-eng.htm The Canadian Coroner and Medical Examiner Database (CCMED) is a new database developed at Statistics Canada in collaboration with the 13 provincial and territorial Chief Coroners and Chief Medical Examiners and the Public Health Agency of Canada. Currently, the CCMED combines data from 9 provincial and territorial databases to provide national information on the circumstances in which deaths reported to and investigated by coroners and medical examiners occur. Understanding these circumstances will facilitate the identification and characterization of emerging trends and unknown safety hazards. Such information will be significant in the CCMED's ultimate goal – the contribution to a decrease in preventable deaths in Canada. Because of the wealth of information contained in the coroner or medical examiner (C/ME) records, in particular the detailed information on the circumstances in which the deaths occurred and the C/ME's final decision on the cause of death, their records are often consulted by researchers. If national data are required, the researchers must visit the offices of all 13 chief C/ME's to identify relevant records and abstract the data. Each jurisdiction has developed a data management system; the CCMED is a response to make the compilation of this data more efficient. The 2006 to 2008 Canadian Coroner and Medical Examiner Report presents data on deaths investigated by a C/ME , with a particular focus on deaths resulting from accidents, suicides, homicides, and deaths of undetermined intent.http://www.statcan.gc.ca/pub/82-214-x/2012001/int-eng.ht The provincial and territorial C/MEs hold data on all deaths that they investigate in their jurisdictions. Depending on the province or territory, the percentage of deaths investigated by a C/ME can range approximately from 7% to 45% annually. Although the criteria for reporting deaths vary somewhat by jurisdiction, deaths caused by natural diseases account for about 61% of all C/ME cases annually 14) Do GOA departments receive the medical examiner reports? 15) Is there any attempt made to review medical examiner reports to prevent the same problems resulting in deaths repeatedly by the GOA? 16) What sort of adverse event reporting system is present in the GOA? I am speaking of Alberta Health, Human Services and Alberta Justice for the most part. Is there a centralized provincial database for all adverse events? If not why not? 17) Are adverse events in specific sites such as hospitals, nursing homes, group homes, child welfare system reportable to the GOA? Are these adverse events also reported to the federal government? 18) What is AHS and Covenant Health doing to reduce adverse events in the medical setting? 19) What is the continuing care industry doing to reduce adverse events in their facilities? 20) What is the GOA reportable incident criteria for health care, medical facilities, dental facilities and continuing care? 21) Who follows up on reportable incidents in Alberta? -- end of message. **********This is an automatically generated email, please do not reply to this email. **********



From: <AlbertaConnects@gov.ab.ca>
Date: Wed, Dec 7, 2016 at 12:12 PM
Subject: RE: Fatality reports, adverse events and tracking recommendations and post adverse event reporting (AC425296)
To:

**********This is an automatically generated email, please do not reply to this email. **********

Thank you for asking a question or sharing your thoughts with the Government of Alberta. We try to respond to all questions within 3 working days. If you need to visit us again, please visit Alberta.ca
Stay in touch

This site is frequently updated to provide you with important information about Alberta programs and services. It's also an opportunity for you to provide your government with feedback on the issues that concern you. Please visit our site again soon to read an article, or send a comment. Internet: Alberta.ca 
(AC425296) 

Your message was 
--
Fatality reports, adverse events and tracking recommendations and post adverse event reporting
In a recent response from Alberta Justice I was told that individual GOA departments are responsible for implementation of fatality report recommendations. Please refer to this e-mail: ---------- Forwarded message ---------- From: Ministry of Justice <ministryofjustice@gov.ab.ca> Date: Tue, Nov 8, 2016 at 10:42 AM Subject: Re: Fatality Reports To:> Cc: Office of the Premier <Premier@gov.ab.ca>   PCU 94078 Dear Ms. Ali: The Honourable Rachel Notley, Premier of Alberta, has forwarded me a copy of your follow-up to Ms. Jennifer Fuchinsky’s email response to you regarding removal of fatality reports from the government website. Premier Rachel Notley has reviewed your correspondence and has asked that I respond on her behalf in my role as Minister of Alberta Justice and Solicitor General. In an email from Jennifer Fuchinsky’s dated October 5, 2016, you were advised that in order to keep the Justice and Solicitor General website up-to-date and to provide an optimum user experience, we review the site’s information for how recent it is. Due to the volume of fatality inquiry reports, we only keep those from the last two years on our website. You were also advised that there was a project in the works to eventually place all fatality inquiry reports online. I am pleased to inform you that this project is now underway and reports pre-dating those on the Justice and Solicitor General website will be uploaded to the Open Government website on an ongoing basis. You can access these reports at the following web address:http://open.alberta.ca/dataset? tags=public+fatality+inquiries&sort=createdate+asc Fatality inquiry reports are distributed to the parties involved in the inquiry and to those who may be impacted by recommendations. The Government of Alberta does not follow up on recommendations as it is these parties who have the authority and responsibility to determine whether recommendations are appropriate to be implemented. When recommendations are directed at a ministry of the Government of Alberta it is the sole responsibility of that ministry to review and determine how or whether it is feasible to implement recommendations in whole, or in part. Thank you for writing to share your concerns with our government and I hope that this information is helpful. Sincerely, Kathleen Ganley Minister of Justice and Solicitor General cc: Honourable Rachel Notley Premier of Alberta This email and any files transmitted with it are confidential and intended solely for the use of the individual or entity to whom they are addressed. If you have received this email in error please notify the system manager. This message contains confidential information and is intended only for the individual named. If you are not the named addressee you should not disseminate, distribute or copy this e-mail. My questions are as follows: 1) Is there a specific section of GOA departments such as Alberta Health and Human Services that review the recommendations of fatality reports? 2) Is there a job order assigned to each recommendation for tracking? 3) Is there longitudinal follow up of each recommendation by each department? 4) When repeated fatality reports issue the same recommendation who is penalized for failures of the GOA departments to successfully implement recommendations? 5) Does anyone in any GOA department ever receive disciplinary action for failures in child welfare or in continuing care? 6) Is there any GOA department other than Alberta Justice reviewing these fatality reports? I assume here that Alberta Justice staff are reviewing these reports. Please correct me if I am wrong. 7) Is it not ultimately the responsibility of the Premier's office to ensure that all GOA departments under the mandate of the Premier's office implement fatality report recommendations? 8) Does any one do any sort of review of all these fatality reports over time? Or do citizens have to do the work of government to determine if the same problems are repeating and no action is being taken? 9) May I at this time also ask why we cannot have the fatality reports stay on the Alberta Justice website. In my opinion this would be sensible and I don't think that having all of them on the site will be a problem since the government has unlimited storage capacity. So why not leave them there? 10) From an e-mail I received about the Open Government portal I was told that there will be ten years of fatality reports uploaded. Can you let me know the total number of years for which the GOA has fatality reports? I was told that ten years of reports will be uploaded by January 2017. Have they only been done for 10 years? This seems surprising to me. 11) How many fatality reports in total are there? 12) Why aren't medical examiner reports filed by Alberta Justice in a similar database? 13) The federal government indicates a wide variation between provinces in medical examiner investigations. What percentage of deaths in Alberta undergo medical examiner review? http://www.statcan.gc.ca/pub/82-214-x/82-214-x2012001-eng.htm The Canadian Coroner and Medical Examiner Database (CCMED) is a new database developed at Statistics Canada in collaboration with the 13 provincial and territorial Chief Coroners and Chief Medical Examiners and the Public Health Agency of Canada. Currently, the CCMED combines data from 9 provincial and territorial databases to provide national information on the circumstances in which deaths reported to and investigated by coroners and medical examiners occur. Understanding these circumstances will facilitate the identification and characterization of emerging trends and unknown safety hazards. Such information will be significant in the CCMED's ultimate goal – the contribution to a decrease in preventable deaths in Canada. Because of the wealth of information contained in the coroner or medical examiner (C/ME) records, in particular the detailed information on the circumstances in which the deaths occurred and the C/ME's final decision on the cause of death, their records are often consulted by researchers. If national data are required, the researchers must visit the offices of all 13 chief C/ME's to identify relevant records and abstract the data. Each jurisdiction has developed a data management system; the CCMED is a response to make the compilation of this data more efficient. The 2006 to 2008 Canadian Coroner and Medical Examiner Report presents data on deaths investigated by a C/ME , with a particular focus on deaths resulting from accidents, suicides, homicides, and deaths of undetermined intent.http://www.statcan.gc.ca/pub/82-214-x/2012001/int-eng.ht The provincial and territorial C/MEs hold data on all deaths that they investigate in their jurisdictions. Depending on the province or territory, the percentage of deaths investigated by a C/ME can range approximately from 7% to 45% annually. Although the criteria for reporting deaths vary somewhat by jurisdiction, deaths caused by natural diseases account for about 61% of all C/ME cases annually 14) Do GOA departments receive the medical examiner reports? 15) Is there any attempt made to review medical examiner reports to prevent the same problems resulting in deaths repeatedly by the GOA? 16) What sort of adverse event reporting system is present in the GOA? I am speaking of Alberta Health, Human Services and Alberta Justice for the most part. Is there a centralized provincial database for all adverse events? If not why not? 17) Are adverse events in specific sites such as hospitals, nursing homes, group homes, child welfare system reportable to the GOA? Are these adverse events also reported to the federal government? 18) What is AHS and Covenant Health doing to reduce adverse events in the medical setting? 19) What is the continuing care industry doing to reduce adverse events in their facilities? 20) What is the GOA reportable incident criteria for health care, medical facilities, dental facilities and continuing care? 21) Who follows up on reportable incidents in Alberta?
--
end of message.

**********This is an automatically generated email, please do not reply to this email. **********



In a recent response from Alberta Justice I was told that individual GOA departments are responsible for implementation of fatality report recommendations. Please refer to this e-mail:


---------- Forwarded message ----------
From: Ministry of Justice <ministryofjustice@gov.ab.ca>
Date: Tue, Nov 8, 2016 at 10:42 AM
Subject: Re: Fatality Reports
To: "
Cc: Office of the Premier <Premier@gov.ab.ca>


PCU 94078

Dear Ms. Ali:

The Honourable Rachel Notley, Premier of Alberta, has forwarded me a copy of your follow-up to Ms. Jennifer Fuchinsky’s email response to you regarding removal of fatality reports from the government website.  Premier Rachel Notley has reviewed your correspondence and has asked that I respond on her behalf in my role as Minister of Alberta Justice and Solicitor General.

In an email from Jennifer Fuchinsky’s dated October 5, 2016, you were advised that in order to keep the Justice and Solicitor General website up-to-date and to provide an optimum user experience, we review the site’s information for how recent it is.  Due to the volume of fatality inquiry reports, we only keep those from the last two years on our website.

You were also advised that there was a project in the works to eventually place all fatality inquiry reports online.  I am pleased to inform you that this project is now underway and reports pre-dating those on the Justice and Solicitor General website will be uploaded to the Open Government website on an ongoing basis.  You can access these reports at the following web address:  http://open.alberta.ca/dataset?tags=public+fatality+inquiries&sort=createdate+asc

Fatality inquiry reports are distributed to the parties involved in the inquiry and to those who may be impacted by recommendations.  The Government of Alberta does not follow up on recommendations as it is these parties who have the authority and responsibility to determine whether recommendations are appropriate to be implemented.

When recommendations are directed at a ministry of the Government of Alberta it is the sole responsibility of that ministry to review and determine how or whether it is feasible to implement recommendations in whole, or in part.

Thank you for writing to share your concerns with our government and I hope that this information is helpful.

Sincerely,




Kathleen Ganley
Minister of Justice and Solicitor General

cc:        Honourable Rachel Notley
            Premier of Alberta

This email and any files transmitted with it are confidential and intended solely for the use of the individual or entity to whom they are addressed. If you have received this email in error please notify the system manager. This message contains confidential information and is intended only for the individual named. If you are not the named addressee you should not disseminate, distribute or copy this e-mail.


My questions are as follows:

1) Is there a specific section of GOA departments such as Alberta Health and Human Services that review the recommendations of fatality reports?

2) Is there a job order assigned to each recommendation for tracking?

3) Is there longitudinal follow up of each recommendation by each department?


4) When repeated fatality reports issue the same recommendation who is penalized for failures of the GOA departments to successfully implement recommendations?

5) Does anyone in any GOA department ever receive disciplinary action for failures in child welfare or in continuing care?


6) Is there any GOA department other than Alberta Justice reviewing these fatality reports? I assume here that Alberta  Justice staff are reviewing these reports. Please correct me if I am wrong.

7) Is it not ultimately the responsibility of the Premier's office to ensure that all GOA departments under the mandate of the Premier's office implement fatality report recommendations?


8) Does any one do any sort of review of all these fatality reports over time? Or do citizens have to do the work of government to determine if the same problems are repeating and no action is being taken?

9) May I at this time also ask why we cannot have the fatality reports stay on the Alberta Justice website. In my opinion this would be sensible and I don't think that having all of them on the site will be a problem since the government has unlimited storage capacity. So why not leave them there?

10) From an e-mail I received about the Open Government portal I was told that there will be ten years of fatality reports uploaded.

Can you let me know the total number of years for which the GOA has fatality reports? I was told that ten years of reports will be uploaded by January 2017.

 Have they only been done for 10 years?

This seems surprising to me.


11) How many fatality reports in total are there?

12) Why aren't medical examiner reports filed by Alberta Justice in a similar database?

13) The federal government indicates a wide variation between provinces in medical examiner investigations.  What percentage of deaths in Alberta undergo medical examiner review?
http://www.statcan.gc.ca/pub/82-214-x/82-214-x2012001-eng.htm

The Canadian Coroner and Medical Examiner Database (CCMED) is a new database developed at Statistics Canada in collaboration with the 13 provincial and territorial Chief Coroners and Chief Medical Examiners and the Public Health Agency of Canada. Currently, the CCMED combines data from 9 provincial and territorial databases to provide national information on the circumstances in which deaths reported to and investigated by coroners and medical examiners occur. Understanding these circumstances will facilitate the identification and characterization of emerging trends and unknown safety hazards. Such information will be significant in the CCMED's ultimate goal – the contribution to a decrease in preventable deaths in Canada.
Because of the wealth of information contained in the coroner or medical examiner (C/ME) records, in particular the detailed information on the circumstances in which the deaths occurred and the C/ME's final decision on the cause of death, their records are often consulted by researchers. If national data are required, the researchers must visit the offices of all 13 chief C/ME's to identify relevant records and abstract the data. Each jurisdiction has developed a data management system; the CCMED is a response to make the compilation of this data more efficient.

The 2006 to 2008 Canadian Coroner and Medical Examiner Report presents data on deaths investigated by a C/ME , with a particular focus on deaths resulting from accidents, suicides, homicides, and deaths of undetermined intent.


http://www.statcan.gc.ca/pub/82-214-x/2012001/int-eng.ht



The provincial and territorial C/MEs hold data on all deaths that they investigate in their jurisdictions. Depending on the province or territory, the percentage of deaths investigated by a C/ME can range approximately from 7% to 45% annually. Although the criteria for reporting deaths vary somewhat by jurisdiction, deaths caused by natural diseases account for about 61% of all C/ME cases annually


14) Do GOA departments receive the medical examiner reports?

15) Is there any attempt made to review medical examiner reports to prevent the same problems resulting in deaths repeatedly by the GOA?

16) What sort of adverse event reporting system is present in the GOA?  I am speaking of Alberta Health, Human Services and Alberta Justice for the most part.  Is there a centralized provincial database for all adverse events? If not why not?

17) Are adverse events in specific sites such as hospitals, nursing homes, group homes, child welfare system reportable to the GOA?

Are these adverse events also reported to the federal government?

18) What is AHS and Covenant Health doing to reduce adverse events in the medical setting?

19) What is the continuing care industry doing to reduce adverse events in their facilities?

20) What is the GOA reportable incident criteria for health care, medical facilities, dental facilities and continuing care?

21) Who follows up on reportable incidents in Alberta?

Contact government

Ask a question or send a message about a government program or service.

No comments:

Post a Comment