Writing a report for the coroner

The coronial process

Coronial systems in Australia operate under state and territory legislation, commonly titled the Coroners Act.

The primary function of the coroner is to:

• determine the identity of the deceased;
• establish how, when and where the deceased died and the medical cause of death; and
• make findings and recommendations aimed at preventing future deaths.

While specific provisions vary by jurisdiction, the fundamental role of the coroner is consistent – to investigate certain categories of death, including unexpected, violent, or unnatural deaths, and deaths occurring in custody or care.

The primary aim of the coronial process is not to look to blame specific parties for the death. The process is geared to explore potential systemic issues that may have contributed to the death, and to make recommendations to prevent future deaths.

That said, the coroner can, and does, report medical practitioners to Ahpra in circumstances where a practitioner’s conduct or performance may have fallen below accepted professional standards.

Medical practitioners may be required to provide clinical records of the deceased and/or a report when they were involved in the clinical care of the deceased, when they attended the deceased prior to death, to clarify medical issues relevant to the death, or when they are involved in death certification where cause is uncertain.

Where will the request come from?

A request for a report or a statement may come from the coroner directly or from a police officer acting on behalf of the coroner. Who the request is sent by does not impact on a doctor’s duty to cooperate.

Consent from the executor of the will of the deceased, or from family of the deceased, is not required when providing records or a statement. Privacy legislation does not override coronial powers.

The obligation to cooperate with the coroner is set out in paragraph 10.11.3 of the Medical Board Code of Conduct:

Good medical practice involves:

10.11.3 Assisting the coroner when an inquest or inquiry is held into a patient’s death by responding to their enquiries and by offering all relevant information.

Where do I start?

A coronial report/statement should generally include:

• an introduction, setting out your name, professional address, and who has requested the statement;
• a summary of your qualifications and experience;
• a summary of the care provided to the deceased (including the period in which you saw them), presenting complaints, medications prescribed, specialist referrals made, and your last contact with the deceased. Where care has been provided by other practitioners, this should be noted. If the outline of the care set out in the statement has been limited to a specific period of time (at the request of the coroner), this should be acknowledged in the statement;
• a response to any specific questions asked by the coroner;
• an expression of condolence to the family of the deceased; and
• a declaration that the contents of the statement are true to the best of your knowledge and belief.

The length and detail of your statement will vary according to the extent of your involvement in the care of the deceased. MDA National can assist you to determine the level of detail appropriate for your statement. Often, you might be one of several doctors providing a piece of the puzzle; it is part of the coroner’s role to piece the entire story together.

Do I need access to the medical record?

When preparing a statement, it’s important to refresh your memory from the medical records. You should never prepare a statement without having access to the records.

In most cases, the coroner is not a medical professional but usually has a legal background. Therefore, the statement should not just explain what medical care occurred but should also seek to explain why certain decisions were made. Medical jargon and abbreviations should be avoided or, if necessary to use, explained in layman’s terms.

When will I hear further?

Once a statement has been provided to the coroner, you may not receive any update for up to (and sometimes more than) a year due to significant backlogs at coronial offices nationwide. If the patient’s cause of death is determined and issued to the deceased patient’s next of kin, you may not hear anything further at all.

The majority of matters in which statements are provided are usually finalised at the investigation stage. Less than 5% of deaths reported to the coroner proceed to an inquest. Inquests are usually held when:

• the death raises public safety concerns;
• there is uncertainty or controversy; or
• systemic issues warrant further examination.

• Coronial matters involving hospital doctors
• When the coroner calls
• When should I report a death to the coroner