Articles and Case Studies

Coronial Matters

27 Nov 2013

Ms Janet Harry

by Ms Janet Harry

It’s almost inevitable that at some point in your medical career, you’ll be asked to manage the death of a patient. MDA National Medico-legal Adviser, Janet Harry provides some hints and tips on how to approach Coronial matters.

Is the death reportable to the Coroner?

Each state and territory has separate legislative provisions for the certification and notification of deaths to the Coroner. You’ll need to check the provisions applicable in your state and follow the tips outlined. Completing a death certificate and reporting a death to the Coroner are mutually exclusive exercises.

If you have concerns about whether the death is reportable to the Coroner, you can get assistance from a number of sources. These include:

  • your registrar, consultant or another experienced medical colleague
  • the Coroner’s office in the state where the death occurs – they may provide telephone assistance to doctors and advise you if the body must remain undisturbed, pending investigation. You can record this advice and the name of the person who assists you in the patient record, for future clarity.
  • MDA National’s 24 hour Medico-legal Advisory Service.
  • Coronial investigations
  • The primary role of the Coroner is to determine:
  • the identity of the person who died
  • the date and place of death
  • the manner and cause of death.

Where a death has been reported, there will be an investigation by the Coroner to determine whether the matter can be dealt with and findings made without needing an Inquest (a Court hearing where witnesses give evidence on oath or affirmation). As one of the treating doctors, you may be asked to provide your evidence, either by written report or by interview, followed by a signed statement. It’s very important that your report or statement is accurate, complete and easily understood. Our Medico-legal Advisory Service can assist you with this. We recommend that you contact us no matter how straightforward the request may seem, as a carefully prepared report will assist the Coroner and can mean that you may not have to give oral evidence later.

Preparing for an Inquest

Occasionally, after reviewing the available evidence, the Coroner will decide that a matter needs to progress to an Inquest. It’s recommended that you contact our Medico-legal Advisory Service immediately on becoming aware of this, whether or not you think you’ll be summoned to give evidence.

Tips on preparing a report or statement for the Coroner

  • Always seek advice from MDA National before providing a report or statement.
  • The report should outline your first-hand knowledge and direct involvement in the patient’s care. You should not prepare a complete summary of the patient’s care.
  • At the beginning of your report, it’s useful to outline your qualifications and your position at the time of the incident/event(s).
  • Always review and use the medical records to prepare your report. Do not rely solely on your memory.

Want to know more?

Contact our Medico-legal Advisory Service on 1800 011 255 or email

Resource link

View our Coronial Reports and Death Certification booklet for a summary of the provisions in each state and territory. MDA National Members can access this booklet from our Member Online Services under the menu item “Education”.

Janet Harry, MDA National Medico-legal Adviser

Anaesthesia, Dermatology, Emergency Medicine, General Practice, Intensive Care Medicine, Obstetrics and Gynaecology, Ophthalmology, Pathology, Psychiatry, Radiology, Sports Medicine, Surgery


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