Human and Medical Error

In performing its mandate, an inquest has a responsibility to determine if changes are needed in the way that institutions and organizations go about their activities, so as to prevent such deaths from recurring. That requirement calls upon judges who preside at inquests in this province to consider the question of medical error and institutional responsibility. While it does not permit inquest judges to declare on the question of culpability (as has been discussed elsewhere), it does permit judges to identify and discuss individual and institutional error.