• Cautionary Tale

    Case Study


    Body of evidence: lessons in writing death certificates

    It sounds like a simple enough request, so you oblige and after visiting the aged care facility where Mrs L is now lying peacefully in her room, you dutifully sign her death certificate.

    At the time, you don’t feel it is necessary to ask any questions and do not report the death to the coroner. 

    Subsequently, you are furious to discover that some of the staff at the aged care facility have covered up the more sinister circumstances of Mrs L’s death and in fact, she fell into a fountain in the nursing home grounds and most likely drowned.

    The police launch an investigation and you are embroiled in an inquest into Mrs L’s death in which your professional approach to writing death certificates is scrutinised. 

    Case history

    At the time of her death, Mrs L was 76 years old and resided in an aged care facility. She had dementia which caused frequent wandering and had a history of falls, angina, atrial fibrillation, and hypertension.

    In late April, 2011, due to an increase in the number of falls Mrs L had sustained, she was referred to Avant’s member for a medical and physiotherapy assessment.

    As a result, the doctor advised the aged care facility that Mrs L required close monitoring and should always be assisted by a staff member when walking. 

    Sadly, on 31 May, 2011, the doctor was informed by a nurse at the aged care facility that Mrs L had been found deceased, lying in the grounds next to a fountain in an internal courtyard from a suspected heart attack. 

    That evening, the doctor visited the aged care facility to write the death certificate for Mrs L who was now lying on her bed. The doctor had noticed a graze on her face, but attributed this to Mrs L’s propensity for falls.

    However, it was soon revealed that staff at the aged care facility had covered up the true nature of Mrs L’s death, after a junior carer working at the aged care home blew the whistle, informing police that she had seen Mrs L in the fountain from an upstairs window in the facility when staff were alerted. 

    A police investigation uncovered telling CCTV footage which showed that Mrs L had actually wandered into the garden bed in the vicinity of the fountain and then returning to the path, accidentally knocked over a garden light adjacent to the path.

    The footage revealed that Mrs L had tripped over the garden light and fallen head first into the fountain, possibly striking her head. She remained motionless in the fountain, lying face down.

    The evidence suggested that staff discovered her fifty minutes later and removed her from the fountain. Two registered nurses did not perform any resuscitation attempts as they believed that Mrs L was already deceased.

    During the inquest into Mrs L’s death, the nurse in charge on the day she died gave evidence that the facility manager had threatened to sack her if she did not falsify progress notes to state that she had been found in the courtyard lying on the ground after suffering a suspected heart attack.

    The nurse told the inquest that a carer had dried off Mrs L and reclothed her in preparation for the family.

    Hampered by the fact that Mrs L’s death was not initially reported to the coroner and the family had arranged for her to be embalmed, the autopsy report found an “undetermined” cause of death, but concluded that Mrs L likely died as a result of immersion.

    However, the forensic pathologist was unable to determine whether Mrs L was rendered unconscious from blunt head trauma and subsequently drowned, or the immersion in cold water may have precipitated a reflex cardiac arrest. 

    The Coroner found the cause of death to be immersion with underlying cause undetermined in circumstances of a fall into a courtyard water feature.

    As a result of the coroner’s inquest, the aged care facility implemented a range of safety measures and provided training for staff to improve safety, resident care and communication. 


    This case emphasises the importance for doctors who are asked to provide a death certificate to ensure they conduct a thorough examination of the body and to ask any relevant questions.

    For example, although the staff at the aged care facility went to great lengths to cover up the true circumstances regarding Mrs L’s death, had the doctor enquired about the graze on Mrs L’s face, the staff may have faltered with their version of events.   

    The doctor conceded that as the death had involved a fall, she should have reported it to the coroner and agreed that when in doubt about whether a death was reportable, it was better to err on the side of caution and report it.

    Members are advised that a cause of death certificate must not be issued if the death is reportable to the coroner.