Pre-registered research · Phase 1

Quantifying institutional delay risk
in healthcare

IDRS is an evidence-based scoring system that measures patterns of institutional healthcare delay using Queensland coronial inquest findings — built for the legal and health insurance sectors.

Join the waitlist Pre-registration ↗

The problem

Preventable deaths follow identifiable patterns.
Those patterns aren't being measured.

Queensland coronial inquests reveal a recurring picture: healthcare institutions where delayed escalation, missed referrals, and dismissed concerns compound into fatal outcomes. Today, identifying these patterns requires thousands of hours of manual review — and the insight rarely reaches the practitioners who need it.

70
Queensland coronial cases
scored and released in Phase 1
22
Institutional failure
pattern types identified
6
Scoring dimensions
per case
OSF
Pre-registered methodology.
Open science standards.
Prior findings on record. In some Phase 1 cases the coronial finding referred to an earlier finding involving the same institution, and in a smaller number the same failure pattern recurred after a coroner had reported on it. IDRS is not publishing a count for these yet. The figure depends on which of several definitions is used, and the strongest version of the claim deserves an independent check before it carries a number.

What IDRS does

Structured risk intelligence
from coronial data

IDRS extracts, structures, and scores healthcare institutional delay from publicly available Queensland inquest findings — producing reproducible, auditable risk scores at the case and facility level.

Automated extraction

Structured data extracted from inquest PDFs using a dual-pass NLP pipeline with human review and tiebreaker logic.

Reproducible scoring

Six-dimensional scoring formula — signal strength, delay weight, severity, escalation, vulnerability, and complaint modifier — with full audit trail.

Facility-level normalisation

Case scores are normalised by facility volume, so a facility is not penalised simply for appearing more often in the public record. Comparative ranking is withheld until the corpus supports it.

Compliant by design

No individual practitioner identification. Pre-registered methodology. Coronial findings are public documents under the Coroners Act 2003 (Qld).


How it works

From inquest finding
to risk score

Three stages — from public court documents to structured, auditable institutional risk intelligence.

Step 1 — Source

Coronial inquest findings

Publicly available PDF findings from the Coroners Court of Queensland, published under the Coroners Act 2003 (Qld). No private health records accessed.

Step 2 — Extract

Structured extraction + human review

A dual-pass NLP pipeline identifies 22 institutional failure pattern types across 6 scoring dimensions. Cases are human-reviewed, with a documented tiebreaker procedure for resolving conflicts between passes.

Step 3 — Score

Facility-level risk score

A six-dimensional formula produces a reproducible risk score per case, normalised by facility volume to enable fair comparison across Queensland Health institutions.


Who it's for

Built for legal, insurance,
and research practitioners

Medical negligence law firms

Quickly find the coronial findings relevant to a client's case, with the institutional delay patterns in each one identified and scored. Every result traces back to a named public document.

Medical indemnity insurers

Portfolio-level risk intelligence on facility-specific delay patterns. Evidence-based underwriting signal from independently sourced coronial data.

Health researchers & academics

Pre-registered, reproducible scoring methodology. Open science framework with OSF pre-registration. Suitable for academic partnership and peer-reviewed output.


Roadmap

Built to scale.
Phase by phase.

IDRS is a platform, not a one-off study. Each phase extends the scope, automation, and reach of institutional risk intelligence.

Phase 1
Complete

Retrospective corpus

70 Queensland coronial cases extracted, scored, and human-reviewed against a pre-registered methodology, across 22 institutional failure pattern types. Findings are reported per case, each traceable to a named public document.

Phase 2 · 2026
In development

Live ingestion + dashboard

Automated ingestion of new coronial findings as published. Interactive facility dashboard. Queensland Health institutions tracked continuously as new inquest findings are released.

Phase 3 · 2027+
Planned

Prospective monitoring

Applying Phase 1 and 2 failure pattern signatures to complaint, incident, and clinical governance data — flagging at-risk facilities before harm occurs, not after. National expansion beyond Queensland.


About

Independent research,
built in Brisbane

JH

Jai Hayward — Independent health researcher

IDRS was built to address a gap between what Queensland coronial findings document and what the health and legal sectors can systematically measure. Institutional failure patterns appear repeatedly across inquest findings — but without a reproducible, auditable method for identifying and ranking them, that information stays buried in PDFs. The project uses a pre-registered methodology, open science standards, and a human-reviewed extraction pipeline to change that. Based in Brisbane, QLD.


Research integrity

Pre-registered methodology.
Open science standards.

OSF pre-registration — Phase 1

IDRS's scoring methodology, corpus definition, and analysis plan are pre-registered on the Open Science Framework before Phase 1 scoring runs. This prevents post-hoc hypothesis changes and ensures results are independently verifiable.

doi.org/10.17605/OSF.IO/3U24Z ↗
Phase 1 corpus
70 cases released
Corpus as at
30 July 2026 · methodology v2.4
Scoring run
Phase 1 scoring complete
Availability
2026 — join waitlist
Jurisdiction
Queensland, Australia
Data sources: IDRS processes only publicly available court documents published under the Coroners Act 2003 (Qld). No patient records, My Health Record data, or private health information is accessed or stored. No individual practitioners are identified or scored.
Scope and limits: An IDRS score measures how an institution responded to documented warning signals in a single coronial finding. It is not a measure of clinical quality, of overall safety, or of the care any individual received, and it does not indicate that an institution is unsafe today. Scores reflect only cases that reached a coronial inquest and were published, which is a small and non-random subset of healthcare outcomes. Absence from IDRS is not evidence of good performance. Findings are reported per case rather than as a facility ranking, because the current corpus is too small to support comparative claims about institutions.
Not advice: IDRS is a research instrument. It is not legal, medical, or financial advice, and it is not a substitute for professional judgement, independent investigation, or reading the underlying coronial finding. Every score links to the public document it came from; that document is the authority, not the score.
If this is personal for you: Some people reading this will have lost someone in the circumstances IDRS measures. Contact details for Lifeline, Coronial Family Services, the Office of the Health Ombudsman and the Coroners Court of Queensland are listed on our what we found page. They are independent of IDRS.

Join the waitlist

IDRS Phase 1 is complete. Join the waitlist to be notified when results are available for your sector.

Or email directly: jaih@idrsystem.com.au