Coronial cases

Coroners often seek statements from medical practitioners when investigating reportable deaths.¹ This chapter outlines the coronial legislative requirements in each state and territory, the coroner’s role in coronial cases and what to consider when reporting a death to a coroner.

The legislation in each state and territory defines a ‘reportable death’ differently; however, it will usually include accidents and suicides, as well as violent, unnatural or unexpected deaths (see Table 1 for legislation details). It can also include deaths after medical care has been provided and deaths that occur in care (such as falls in RACFs) or in custody.¹ 

The coroner’s role is to determine:

• the identity of the deceased
• when and where they died
• the circumstances and cause of death.^1,2 

The coronial process is an investigative process that often involves reviewing all aspects of care and clinical decisions leading up to a patient’s death. Most deaths referred to the coroner are finalised without needing a formal inquest. However, the process can sometimes (relatively uncommon) lead to civil or disciplinary action or even criminal proceedings if the coroner is critical of the care provided or refers information to a third party. Coroners may also make recommendations to governments and other agencies with a view to improving public health and safety.¹ 

Preliminary coroner investigations are typically conducted by the police under the coroner’s instruction. 

It is generally appropriate for a GP to cooperate with a request received from the coroner (eg requests in writing for records, to provide a statement) or to seek advice from the coroner if they are unsure about the reporting of a death/issuing a death certificate. The GP should consider obtaining advice from their medical defence organisation if there is anything they are unsure about, and especially if they were involved in providing treatment to the patient prior to their death. 

A cause of death certificate cannot be issued if the death is reportable to the coroner (and knowingly failing to report the death may be an offence). This should be determined before the body of the deceased patient is transferred (eg to a funeral home). 

The circumstances for reporting death vary between states and territories. However, in general, a death should be reported to the coroner in the following circumstances:

• the cause of death is unknown (ie the GP is not ‘comfortably satisfied’ as to the cause of death)
• the cause of death is unnatural, violent, suspicious or unusual
• the death resulted directly or indirectly from an accident or injury (in NSW, there is an exception that may be available if the person was 72 years or older and the injury was attributable to their age)
• the death occurred when the person was in police, or other lawful, custody; or where the person was held in care (eg in a mental health facility or residential service, including children)
• the death is an unexpected result of healthcare or a procedure (this can be complex, and advice should be sought, because the threshold varies between jurisdictions; includes under/the result of an anaesthetic [Western Australia], because of or within 24 hours of an invasive procedure/anaesthetic or within 24 hours of discharge for emergency hospital care [South Australia] and during or as a result of an anaesthetic and not natural causes [Northern Territory]).⁴ 

GPs should be aware of and follow the rules that apply regarding reportable deaths in the state or territory in which they are practising. 

GPs should be aware that RACFs have separate obligations to report unexpected deaths to the Aged Care Quality and Safety Commission within 24 hours. 

If a GP is unsure whether they should be writing the death certificate, it is advised they contact their medical defence organisation for advice. Alternatively, GPs can seek telephone advice from the appropriate state/territory coroner’s office (details provided in Table 2). It should be noted that contacting coroners after hours can be difficult. 

The Medical Certificate of Cause of Death (‘death certificate’) is an important legal document. The completion of a death certificate by a medical practitioner is a vital part of the notification process of a death to the Registrar of Births, Deaths and Marriages in the relevant state or territory in which the death occurred, and enables an authority to be provided to the funeral director to arrange disposal of the body.³ 

Generally, you must complete the death certificate within 48 hours from the time of death. You can sign a death certificate if you are satisfied:

• the death does not need to be reported to the coroner
• about the cause of death, because:
  • you were responsible for a person’s medical care immediately before death
  • you examined the body and/or have sufficient information (eg through a review of the medical records or discussion with the treating doctor) about the probable cause of death.^3,4

The format of Australian death certificates varies slightly in each state. See Table 3 for details of Australian registries of births, deaths and marriages. 

What should be included in a death certificate?

A death certificate must contain demographic details and the cause of death, including antecedent causes and contributing causes with relevant time frames, as required by the applicable legislation. 

Disease or condition directly leading to death

If conditions such as cardiac arrest, respiratory failure or chronic renal failure are entered as the disease or condition directly leading to death (on Line I(a)), always enter the underlying cause(s) on the lines following (Lines I(b), I(c) and I(d)) to indicate the sequence of events leading to death. 

Antecedent causes

Antecedent causes should be listed with the disease or condition directly leading to death at the top of the certificate. For example, the disease or condition directly leading to death (direct cause) will have the shortest interval before death and the final antecedent cause (ie the underlying condition) will have the longest interval. 

Other significant conditions contributing to the death, but not related to the disease or condition causing it

Generally, these are conditions are not involved in the direct causal train of events that lead to the death but the conditions ‘… prevented the person from recovering from or overcoming the disease’.⁵

• How to complete a death certificate: A guide for GPs
• Australian Bureau of Statistics: Guidance for certifying deaths due to COVID-19
• Australian Bureau of Statistics: Cause of Death Certification Australia - Quick Reference Guide
• Australian Bureau of Statistics: information paper: cause of death certification Australia
• A useful service to direct families of recently bereaved patients to: https://deathnotification.gov.au/