Coronial findings for CPD
How to turn published coronial findings into “measuring outcomes” CPD, with the wording from 15 colleges' CPD programs quoted and linked.
Why coronial findings
Most doctors registered in Australia need 50 hours of CPD a year. Of these, at least 25 hours must be in reviewing performance and measuring outcomes, with a minimum of five hours of each. Measuring outcomes can be the hardest to fill, especially without a procedural logbook or a ready-made audit.
The Medical Board of Australia's list of measuring outcomes activities includes, under activities not directly focused on the participant's practice:
assessing incident reports
leading, analysing, writing reports on healthcare outcomes
A coronial finding is a detailed, public, independently investigated account of a death, often with specific recommendations. Coronial lets you search findings from all Australian jurisdictions by clinical theme, which is much quicker than searching each court's website separately.
Reading alone is unlikely to count as measuring outcomes
Reading coronial findings is valuable, but on its own it is generally treated as an educational activity (or, for some colleges, reviewing performance). To count as measuring outcomes, the activity will usually need to analyse outcomes against a standard, relate them to your own practice or service, and lead to an action, ideally one you later re-measure. Your CPD home decides what counts. The college-by-college section below quotes each college's own wording so you can check your activity against it.
Must the incidents be your own? Most colleges list incident review, M&M or critical-incident discussion without saying whose incidents they mean. The Medical Board lists “assessing incident reports” among activities not directly focused on your own practice, and ANZCA's activity is built on published reports. Some colleges, however, frame measuring outcomes around your own patients or work data, and an assessor may read incident review as meaning your own unit's events. Tying the coronial cases back to your own practice (“could this happen here?”, followed by a local action) may cover either reading. If you are unsure, check with your college's CPD team before claiming the hours.
Three activities that may work
Activity 1 · Group review of published outcomes
A facilitated meeting where 3–12 colleagues analyse a set of coronial findings on one theme and agree what should change locally. This is the model in ANZCA's Analysing healthcare outcomes guideline.
- Choose a theme relevant to everyone's scope of practice, and search Coronial for it.
- Pick 3–6 findings that show different failure points. Circulate the original findings (not only our summaries) beforehand.
- At the meeting, go through each case: context, what happened, contributing factors, and the coroner's recommendations.
- Spend at least half the time on implications. Could this happen here? What do our guidelines, equipment and staffing look like? What would we change?
- Agree on actions, with an owner for each, and record them. Each attendee completes their college's record or verification form.
Activity 2 · Coronial-informed audit of your own practice
The strongest option: an audit of your own practice fits every college's definition of measuring outcomes. Coronial findings supply the standard, and your own practice supplies the data.
- Search Coronial for a theme and read the coroners' recommendations. Pick one specific, measurable standard: for example, documented sedation scores for every patient on a PCA, or an X-ray check of NG tube position before first use.
- Collect data on your own patients or service against that standard (20–30 consecutive cases is a common starting point).
- Compare your results with the standard and identify the gap.
- Make a change: a protocol, a checklist, education or an order-set default.
- Re-audit after the change and record the result. This closes the loop that RACP, RANZCP and ACRRM describe.
Activity 3 · Thematic review and written report
An individual review of a series of findings on one theme, written up as a short report for your department, M&M meeting or committee. The Medical Board lists this type of work as measuring outcomes, but colleges vary in how readily they accept it without your own practice data.
- Define a focused question: for example, contributing factors in coronial deaths involving inpatient falls on anticoagulants.
- Search Coronial and record your search terms, filters and the date. Use the CSV export to tabulate the cases.
- Read each original finding. Code the recurring contributing factors and the coroners' recommendations.
- Compare those factors with your local policies and identify where the same gap could exist.
- Write up 1–2 pages of findings with recommendations, and present them to the group that can act on them.
Starter topics
Each link opens a Coronial search. Narrow the results with the state, setting and specialty filters, then read the original findings.
- Opioid-induced respiratory depression on the wardAnaesthesia, pain, medicine, nursing
- Missed or delayed recognition of sepsisED, ICU, general medicine
- Nasogastric tube misplacementMedicine, ICU, radiology
- Suicide after discharge or a declined admissionPsychiatry, ED, general practice
- Anaphylaxis recognition and adrenaline useED, anaesthesia, general practice
- Postpartum haemorrhageObstetrics, anaesthesia
What each college says
Quotations are taken verbatim from each college's published CPD documents, last checked October 2026. Colleges revise their programs, so follow the link and check the current version before you claim hours. Of the documents we reviewed, only ANZCA's documents name coronial findings explicitly. Most other colleges list “assessing incident reports” or “writing reports on healthcare outcomes”, wording taken from the Medical Board's framework, and that is where coronial work is most likely to fit. For colleges other than ANZCA, the “how it fits” notes are our reading of their criteria, not college guidance.
Category 3 – Measuring Outcomes
Australasian College of Dermatologists
“Measuring outcomes involves measurement of health outcomes, such as an audit of your practice or management against standards or guidelines, such as incident reporting or reviews.”
How it fits: Activity 2, with a coroner's recommendation as the standard: for example, on following up suspicious skin lesions, or on mental health monitoring during isotretinoin treatment.
ACEM
↑ All collegesMeasuring Outcomes
Australasian College for Emergency Medicine
“Measuring Outcomes has a focus on patient outcomes.”
“Peer discussions of cases, critical incidents, safety and quality”
“Critical incident monitoring”
How it fits: Activity 1 run as a departmental safety and quality discussion, or Activity 2 auditing your ED against a coroner's recommendation.
ACRRM
↑ All collegesOutcome Measurement
Australian College of Rural and Remote Medicine
“Case-based discussion can be claimed in the Outcome measurement category, where the discussion has prompted changes to practice which can then be evaluated.”
“A clinical audit is a process that seeks to improve the quality of patient care and outcomes by measuring current practices against best practices and implementing changes if required.”
How it fits: Activity 2 follows ACRRM's five audit steps closely. ACRRM's wording suggests Activity 1 may count once the discussion leads to a change you then evaluate.
ACSEP
↑ All collegesMeasuring Outcomes
Australasian College of Sport and Exercise Physicians
“Leading, analysing, or writing reports on healthcare outcomes”
“Critical Incident review and analysis.”
How it fits: Activity 3, or Activity 1 framed as a critical incident review. Sport-related deaths, including cardiac events and concussion, appear in coronial findings.
ANZCA / FPM
↑ All collegesCategory 1 Practice evaluation – measuring outcomes: Analysing healthcare outcomes
Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine
“Published healthcare incident reports, such as: … Coronial findings in the public domain. Coronial Communiqués.”
“Analysing healthcare outcomes: this is a group activity to analyse a published report on healthcare outcomes (e.g., a coroner’s report, WebAirs reports, ANZCA professional documents) and reflect on the implications for your practice.”
“As this is a Practice evaluation activity, the facilitator should ensure a significant proportion of the time (suggested at least half) should be spent discussing implications for practice and next steps (as relevant).”
How it fits: The only college whose CPD documents we found naming coronial findings outright. Activity 1 follows its guideline. It is a facilitated group activity (minimum 3 attendees), and the Analysing healthcare outcomes CPD verification form is uploaded as evidence.
CICM
↑ All collegesMeasuring outcomes / Measuring and improving outcomes (Category 3)
College of Intensive Care Medicine of Australia and New Zealand
“Measuring outcomes includes investigating the outcomes of everyday work by analysing and reflecting on data about their patients’ health outcomes. These activities may include morbidity and mortality (M&M) meetings, critical incidents, root cause analysis and multi-disciplinary team meetings.”
“Activities not directly focused on clinical practice: drafting reports on healthcare outcomes”
How it fits: Activity 2 is the safest fit, since the emphasis is on your own patients' outcomes. Activity 3 appears to match “drafting reports on healthcare outcomes”. Activity 1 can work as an M&M-style meeting if it ends in a comparison with your own unit's practice.
RACGP
↑ All collegesMeasuring Outcomes (MO)
Royal Australian College of General Practitioners
“Indications it could be MO are that you: used work data to validate what you do; used work data to improve what you do; compared your approach to best-practice guidelines; implemented a change to your work.”
“Examples of MO activities: … incident reporting and analysis … leading, analysing, writing reports on healthcare outcomes”
“Meetings - Clinical Review, Practice, Morbidity and Mortality, Multidisciplinary Team, Case Review, Evidenced Based Journal Club, Peer Group Learning (with clinical focus)”
How it fits: RACGP files case-review and M&M-style meetings under Reviewing Performance, so Activity 1 is most likely to count there. The RACGP guide also treats “thought about how what you read / watched / heard matters to your work” as Reviewing Performance. Activity 2 (a mini audit of your own patients) or Activity 3 is more likely to qualify as MO.
RACMA
↑ All collegesMeasuring Outcomes (AUS) / Measuring and Improving Outcomes (NZ)
Royal Australasian College of Medical Administrators
“These are activities in which the outcomes of your practice or of your organisation are measured and reviewed against established standards.”
“Leading, analysing and writing reports on healthcare outcomes”
“Measuring outcomes focuses on undertaking audits, assessing the impact of practice changes and identifying areas for improvement.”
How it fits: Activities 2 and 3 at service level, since RACMA explicitly includes your organisation's outcomes. For example, check your health service's response to every coroner's recommendation directed at it, or at services like it.
RACP
↑ All collegesCategory 3 – Measuring outcomes
Royal Australasian College of Physicians
“Category 3 Involves measurement of health outcomes and might include an audit of standards or guidelines, practice against relevant EVOLVE recommendations, or incident reporting/monitoring.”
“Measuring outcomes focuses on evaluating the impact of changes in practice on patient care or outcomes. These activities support quality improvement and evidence-based practice.”
How it fits: Activity 2. Coroners' recommendations can provide the standard for an “audit of standards or guidelines”, and the re-audit shows the impact of the change.
RACS
↑ All collegesAudit and Peer Review (10 h) · Performance Review (15 h)
Royal Australasian College of Surgeons
“Peer discussions of critical incidents, safety and quality reviews”
“Meetings reviewing adverse events”
“Participants in operative practice must include an audit of their procedures.”
“Be benchmarked against minimum standards, guidelines or relevant research for that procedure/s (e.g. Colonoscopy Clinical Care Standard)”
How it fits: RACS splits the Board's 25 hours into Audit (10 h, the measuring-outcomes category) and Performance Review (15 h). Its Audit is strictly an audit of your own procedures, so coronial findings can only serve as the benchmark for a focused audit (Activity 2). Its Performance Review list, though, recognises peer discussion of critical incidents and adverse events, so Activity 1 is likely to count there. That still counts toward the 25 hours, just not as Audit. Surgeons also already review surgical deaths through ANZASM, which the Medical Board mandates for surgeons.
RANZCO
↑ All collegesMeasuring Outcomes
Royal Australian and New Zealand College of Ophthalmologists
“Clinical healthcare evaluation and reports (leading, analysing, writing reports on healthcare processes and outcomes. Can also be PR hours, only claim in one or the other category.)”
How it fits: Activity 3, which RANZCO's 2024 handbook credits at 5 hours per report. Activity 2 is also likely to fit as an audit of your own practice.
RANZCOG
↑ All collegesOutcome Measurement (OM)
Royal Australian and New Zealand College of Obstetricians and Gynaecologists
“Includes measurement of outcomes of care, benchmarking of performance with peers and reflecting on patient outcomes.”
“Compare processes or health outcomes with best practice: An approach to evaluate and improve the effectiveness of a process which contributes to the safety, effectiveness or efficiency of healthcare delivery.”
“Assessing incident reports … This activity involves time spent assessing the incident report for structure and accuracy.”
How it fits: RANZCOG's “assessing incident reports” is defined narrowly, as checking an incident report's structure and accuracy, so it is unlikely to cover reading published findings. Activity 2 is the better fit, as a clinical audit or a comparison of your unit's processes with best practice: for example, against a coroner's postpartum haemorrhage recommendations. Activity 3 may fit its “Reports on healthcare outcomes” activity, but that is less certain.
RANZCP
↑ All collegesSection 3 – Practice Improvement / Measuring Outcomes
Royal Australian and New Zealand College of Psychiatrists
“Section 3 activities adopt a systematic approach to practice improvement and may take longer than one calendar year to complete. They involve critical review of your own or your service’s practice, deliberate implementation of change and a monitoring component. They involve use of the Plan-Do-Study-Act principle”
How it fits: Activity 2 is the only one likely to meet Section 3: the cases supply the standard, and you then audit your own service, make a change and monitor it. Reading or discussing findings on its own would more likely fall under Section 4 (self-guided learning).
RANZCR
↑ All collegesMeasuring and Improving Outcomes
Royal Australian and New Zealand College of Radiologists
“Leading, analysing, writing reports on healthcare outcomes”
“Incident reports (including assessing incident reports)”
How it fits: Activity 3 is listed almost word for word for clinical radiologists, and “assessing incident reports” for radiation oncologists. Missed or delayed imaging diagnosis comes up in many coronial findings.
RCPA
↑ All collegesCategory C – Measuring Outcomes (Quality and outcomes measures)
Royal College of Pathologists of Australasia
“This category concerns the measurement of quality, outputs and outcomes against standards, guidelines, performance expectations, or large datasets e.g. interdepartmental, national, or best practice guidelines.”
“Participation in incident monitoring. For example, KIMMS, or other mechanisms to evaluate pre or post-analytical factors impacting on diagnostic accuracy and patient care. This may include evaluation of appropriateness of test ordering, specimen collection and transport, communication and follow-up of test results etc.”
How it fits: Activity 2. Coronial findings involving abnormal results that were never acted on could provide the standard for an audit of how your laboratory communicates critical results. The RCPA CPD documents we reviewed mention coroners only for forensic pathologists' own post-mortem work, not for learning from published findings.
Is your college missing, or has its guidance changed? Let us know. Every CPD home follows the Medical Board's framework, so the Board's Types of CPD page is a fair starting point for colleges not listed. RACP's MyCPD Handbook is available only to members, and we found no public CICM handbook, so those two entries rely on the colleges' public web pages.
Using findings responsibly
- Each finding concerns a real person who died, and a family who may still be grieving. Discuss the cases with that in mind.
- Use only what is in the public domain. As ANZCA's guideline notes, group discussion of your own cases has no qualified privilege, so de-identify anything from your own practice.
- Coronial's summaries and tags are AI-generated and can contain errors. Always work from the original finding, linked from the case page.
- Coronial is an independent resource and is not endorsed by any college. Whether an activity counts toward your CPD is decided by your CPD home.