- Do not provide a signed statement or enter into detailed conversations with police without first contacting Avant.
- If you receive a summons to give evidence at a coronial inquest you should contact Avant immediately so that we can
assist you in the process.
- Coronial investigations can be lengthy and stressful – even if there is no criticism of your care. Make sure you seek support.
The role of the coroner
Many medical practitioners at some stage in their career find themselves involved in coronial proceedings. Coroners often
seek statements from medical practitioners when investigating reportable deaths.
The legislation in each state and territory defines a ‘reportable
death’ somewhat differently however it will usually include
accidents and suicides, as well as violent, unnatural or
unexpected deaths. This can include deaths after medical care
has been provided. It can also include deaths that occur in care
or in custody
The coroner’s role is to determine the identity of the deceased
as well as when and where they died and the circumstances and
cause of death.
The coronial process often involves reviewing all aspects of care
and clinical decisions leading up to the patient’s death. The
majority of deaths referred to the coroner are finalised without
needing a formal inquest. However, the process can lead to
civil or disciplinary action or even criminal proceedings if the
coroner is critical of the care provided. Coroners may also make
recommendations to governments and other agencies with a
view to improving public health and safety.
The preliminary investigation and gathering of evidence for
the coroner is generally conducted by the police under the
Providing a statement for the coroner
You may become involved in the coronial process if you
provided medical care to the deceased. You may be approached
by the police or coroner’s staff to provide verbal information or
with a request for a formal legal statement.
We strongly recommend you notify Avant as soon as possible
and before you provide any statement or enter into detailed
conversations with police, even if you are confident there will
be no questions about your care. Statements are requested
at the early stage of an investigation, when it may not be clear what all the issues are going to be and what the autopsy
and investigative reports will show. It is important you don’t
inadvertently compromise your rights. It is perfectly acceptable
to say you are willing to assist once you have spoken to your
medical defence organisation.
Even if the death occurred in a hospital setting and you are
indemnified by the hospital, we still recommend you contact us.
Our role will be to support you through the process and ensure
your interests are protected.
Avant assists its members with this process. It is our usual
practice to cooperate with the coroner’s request and the police
during the investigation process by assisting and advising
you on how to respond. For example, it is not advisable for
you to comment upon the care provided by other medical
practitioners in your statement – concentrate on your
involvement in the matter. Further guidelines on how to
construct a statement are available in our factsheet: Avant How to write a coronial statement.
Once a statement has been obtained from the relevant
witnesses, those assisting the coroner may seek an independent
expert report commenting on the role of the various individuals
in the care and treatment of the deceased.
End of the investigation
The coroner will review all of the evidence and determine
whether an inquest (a court hearing) is necessary.
If the manner and cause of death are clear, the coroner will usually
dispense with an inquest. A great majority of coronial proceedings
are finalised by the coroner without the need for an inquest.
If, however at the conclusion of the investigation, the manner
and cause of death remain unclear, the coroner will usually hold
an inquest. Coronial investigations and inquests can be both
complex and lengthy.
Practitioners are asked to give evidence at inquests for a variety of
reasons. Often the practitioner’s involvement is not contentious. They simply possess one or two pieces of the factual jigsaw
puzzle that the coroner needs to assemble. Avant will help you
appreciate the nature and the extent of your involvement as the
If you have provided a statement to the coroner and an inquest
is held, it is likely that you will be summoned to give evidence
at the inquest. Occasionally, you may be asked to attend court
to give evidence at short notice. This may be because it is not
until the inquest commences that it becomes clear that further
evidence is needed. In either case you should contact Avant
immediately so that steps can be taken to ensure your interests
When you request assistance Avant will advise you on your
position and the need for you to have legal representation at
the inquest. If Avant appoints a lawyer to represent you, the
lawyer will contact the coroner’s court advising that they will be
seeking leave to appear for you at the inquest.
The investigating officer will compile a brief for the coroner
which contains all relevant statements, medical records, autopsy
reports and expert reports obtained by the coroner in relation to
the investigation. Your solicitor or lawyer (not Avant) will obtain a
copy of the coronial brief and review it to identify possible areas
for adverse comments that the coroner may find.
If called to give evidence, you will be asked to adopt or confirm
the statement you have previously provided. Those people who
have an interest in the matter are then entitled to ask questions
in cross-examination. Generally, at the end of such questioning,
you will be asked questions by your lawyer to clear up any
ambiguities or issues that may have arisen.
It is important to remember that an inquest is a fact-finding
exercise, and not a method of apportioning blame. The rules of
evidence do not apply in the coroner’s court and those called to
give evidence are either factual or expert witnesses.
Inquest hearing time can vary from days to many weeks
depending on the complexity of the case and the number of
witnesses called to give evidence. Generally, we will be notified
of the amount of time the inquest is ‘set down’ for. Regardless of
the duration of the inquest, as a witness you should be excused
after giving your evidence which may range from a few minutes
to a day or two.
The result of a coronial inquest
After the inquest the coroner will hand down their findings
and sometimes make recommendations. Although it is not a
court of blame, sometimes coroners may be critical of a medical
practitioner and refer them to a disciplinary body such as a state health care complaints body or Ahpra, following which
a separate assessment or investigation will take place into the
The coroner may form the view that there is a case for criminal
charges to be brought against an individual. If so, the coroner will
suspend the inquest and forward the documents to the director
of public prosecution. Fortunately, this is a rare event concerning
After the coroner has handed down their findings, the deceased's
family may consider bringing a compensation claim alleging
negligence and seeking damages against individual practitioners.
Publicity and talking to the media
Inquests are generally open to the public and sometimes attract
publicity. We recommend you do not speak to the media about the
matter as this may prejudice not only the coronial proceedings but
any subsequent proceedings or disciplinary investigation.
Support throughout the process
As coronial investigations often take more than a year for the
evidence to be gathered, the process can be drawn out and
stressful. At the inquest the patient’s family are likely to be
distressed and seeking answers. These factors can compound
the significant emotional impact of a patient’s death and are
important reasons to make sure you are supported through the
process. We can support you by:
- being the point of contact for the police and the coroner’s office
- ensuring you have all available material and helping you to
draft coronial statements
- reviewing your statement from a medical and legal
perspective to help you provide an accurate report while not
inadvertently compromising your interests or your rights
- providing peer medical support
- advising and assisting through the investigation
- representing you at inquest
- connecting you with our Personal Support Program on 1300 360 364 or Doctor’s Health Advisory Service if required.
Note: Assistance to Avant members is subject to the terms, conditions and exclusions of the policy
For more information or immediate medico-legal advice, call us on 1800 128 268, 24/7 in emergencies.
*IMPORTANT: This publication is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practise proper clinical
decision making with regard to the individual circumstances. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate
professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact
with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published. © Avant Mutual Group Limited 2021 [July2021]