Report a Death to the Coroner

🔎 When Should I Report a Death to the Coroner?

• JMOs must decide whether:
  • A death needs to be reported to the Coroner, or
  • A death certificate can be issued.
• A death should be reported if:
  • The cause of death is unknown.
  • Any criteria in Table 1 (jurisdiction-specific coronial reporting criteria) are met.
  • The JMO cannot form an opinion on probable cause of death.
• Note:
  • Issuing a death certificate and reporting a death to the Coroner are mutually exclusive.
  • If unsure, seek advice from:
    • The Coroner’s Office
    • Medical Indemnity

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Preparing a Report to the Coroner

📌 When will you be asked?

• Request may come from:
  • Medical administration
  • Hospital legal department
  • Police assisting the Coroner
• May be verbal or written.

What should you do first?

• Seek immediate advice from Medical Indemnity
  • Especially important if the case may proceed to a Coronial Inquest.
  • Legal support may be needed.
• Ask your hospital to review the report before submission.

What should be included?

• Patient’s full name and date of birth
• Your full name, qualifications, and clinical role at the time
• A chronological account of your direct involvement in care
  • Include key dates, times, and events

General principles:

• Use medical records as your primary reference
• Include only first-hand information
• Identify other practitioners involved—do not summarise their care
• The Coroner uses multiple statements to reconstruct the events (“jigsaw” approach)

❓ Answering Coroner’s Questions

• Answer clearly and succinctly
• If you don’t know the answer, it’s acceptable to state that
• It is not an exam—you’re not expected to answer everything

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Categories of Reportable Deaths

Reportable if any of the following apply:

• ✅ Identity of the person is unknown
  • Must be reported to police (Form 1A cannot be used)
• ✅ Death was violent or unnatural
  • Includes:
    • Accidents
    • Suicide
    • Homicide
    • Trauma (e.g., MVA, falls with head injury or #NOF)
    • Drug, alcohol, poison-related deaths
    • Drownings
  • Reportable even if there is a delayed death after the incident
  • Suicide, homicide, workplace or traffic-related deaths must be reported to police
  • Form 1A can be used in appropriate cases
• ✅ Death occurred in suspicious circumstances
  • Must be reported to police
  • Coronial inquest postponed if criminal charges are likely
  • Form 1A not permitted
• ✅ No cause of death certificate issued or likely to be issued
  • If the doctor cannot determine cause of death
  • Must report to police
  • Coroner may order an autopsy

🏥 Health Care Related Deaths

Reportable if both:

1. Health care caused or contributed to the death, or failure to provide it did;
2. The death was an unexpected outcome of the health care.

✔ Definitions:

• Health care = medical, surgical, dental, diagnostic, therapeutic procedure (incl. anaesthetic/drug)
• Contributed to death = person would not have died at that time without the healthcare

✔ Assess using:

• Would the person have died around the same time without the health care? → Yes/No
• Was death due to the natural progression of disease/injury? → Yes/No
• Was care provided with reasonable skill? → Yes/No
  → If any are “No”, the death is reportable

✔ Unexpected outcome:

Ask from the perspective of a professional peer:

• Was death more likely than not before the care was given?
• Was the patient told death was likely?
• Was the decision to treat reasonable based on condition/quality of life?
  → If any are “No”, the death is reportable

🧑‍🦽 Deaths in Care

Reportable if the person:

• Had a disability and lived in NDIS-supported accommodation or received high-level support
• Was detained or assessed under Mental Health Act 2000 or Forensic Disability Act 2011
• Was a child:
  • Awaiting adoption (Adoption of Children Act 1964)
  • Under Child Safety orders (Child Protection Act 1999)
• Death reportable even if occurred in hospital

🚔 Deaths in Custody or Police Operations

• Must be reported if:
  • Person died in custody, escaping, or avoiding custody
  • Death was during police operations
• Always reported to police

👶 Are Stillbirths Reportable?

• ❌ No, under Coroners Act, coroners cannot investigate stillbirths
• Stillbirth = no signs of life after full deliveryAND:
  • Gestation > 20 weeks, or
  • Weight > 400g
• Coroner may order autopsy to confirm stillbirth, but investigation must cease once confirmed

🕵️‍♂️ Preserving the Scene in Healthcare Settings

Health care providers must balance:

• Forensic needs of investigation
• Ability to continue treating other patients
• Family’s need for contact with the deceased

⚠️ State coroner guidelines exist for managing evidence in healthcare-related deaths.

Condition	NSW	VIC	QLD
CAUSE OF DEATH
Unknown	✔	✔	✔
Unexpected (following healthcare procedure)	✔	✔	✔
Unnatural or violent	✔	✔	✔
Suspicious or unusual	✔		✔
NATURE OF DEATH
Identity unknown		✔	✔
Resulted directly or indirectly from an accident or injury	✔	✔	✔ Unnatural or violent
Not attended by medical practitioner
During or as a result of anaesthetic/surgical/invasive procedure	✔ if not reasonably expected outcome	✔ if not reasonably expected outcome	✔ if not reasonably expected outcome (includes failure to provide healthcare)
Not a reasonably expected outcome of a healthcare procedure	✔	✔	✔
Within 24 hours of hospital discharge or emergency treatment
In police or other lawful custody	✔	✔	✔
Held in care (e.g. mental health facility, residential service)	✔	✔	✔