• Coronial inquiries

    The Coronial Process

    Dealing with the coroner

    Avant’s Medico-Legal Advisory Service regularly receives calls from members on how to deal with a request from the coroner or police for a statement regarding a patient’s death. The approach from the coroner is sometimes to obtain information from the doctor to help ascertain the cause of death, at other times, the approach may be to obtain a statement from the doctor regarding the care they provided before the patient’s death. In either case, Avant provides advice, support and legal representation (if required) to members when dealing with requests for information by the coroner. The following is a summary of key features of a coronial investigation and hearing.


    Reminder from Avant risk iQ

    The Coroner and You

    Role of the coroner

    The role of the coroner is to investigate deaths and inquire into fires and disasters. Facts such as the identity of the deceased, the cause of death, the circumstances of the death, and persons who contributed to the death are matters that may be considered by the coroner.

    The coroner is assisted generally by the police. Following a report of a death, the police will investigate the death and the coroner will review the evidence and decide if an inquest is needed to determine the manner and cause of the death.

    The coroner makes no finding of guilt of the parties, but can and often does make recommendations or refer matters for consideration to other bodies in the relevant State or Territory such as health registration boards, relevant Government departments and to the Director of Public Prosecutions (DPP) if he or she believes that an indictable offence has been committed in connection with a death. While it is not the coroner’s role to establish negligence, they can express criticism and/or identify a person who they consider may have contributed to a death. Accordingly, the official findings of a coroner often serve as the catalyst for relatives of the deceased when deciding to commence civil action for monetary compensation against a doctor.

    Reportable deaths

    Legislation in each State and Territory outlines when a death must be reported to the coroner. The definition of a ‘reportable death’ is slightly different in each jurisdiction, but categories of 'reportable deaths' common to most jurisdictions include:

    • The identity of the person is unknown
    • Unexpected, unnatural or violent deaths, including deaths in suspicious circumstances or deaths resulting directly or indirectly from an accident or injury
    • The death of a person held in care or custody
    • Health care related deaths
    • Deaths occurring while under anaesthetic, or as a result of the administration of an anaesthetic and not due to natural causes
    • The death of a person where the cause is unknown

    If the manner and cause of death are clear, the coroner will usually dispense with an inquest. Many coronial investigations do not proceed to inquest and the file is closed by the coroner at an early stage.

    Access to clinical records

    In all jurisdictions, the coroner is authorised to inspect any place and take a copy of any relevant documents including clinical records, for the purposes of the investigation. The coroner may also give a police officer written authority to enter and inspect premises, copy documents and seize property.

    The inquest

    An inquest is a court hearing conducted by a coroner to primarily determine the manner and cause of death and make findings. A coroner’s inquest is open to the public except in special circumstances. The coroner has discretion to give any person leave to appear at the inquest and to be legally represented. Leave will almost always be given to medical practitioners involved with the care of the deceased and the family of the deceased. The coroner is not bound by rules of evidence and generally has discretion to conduct the proceedings as they see fit, although in practice the procedure closely resembles a court hearing.

    The witness

    Witnesses are summonsed to give evidence at the inquest. In some States it is a specific offence for a witness to refuse to be sworn or give evidence. Witnesses give evidence from the witness box and swear an oath or make an affirmation to tell the truth. The witness is asked to give their name, address and occupation. The statement of the witness will be read out. The witness will be asked to confirm that it is their statement and that they do not wish to make any changes to it. Counsel assisting the coroner can then ask the witness questions which expand on what they have said in their statement. Lawyers also have the opportunity to ask the witness questions. Counsel assisting the coroner then has a further opportunity to ask more questions to clarify any issues that arise. The coroner can always ask questions along the way and request other witnesses to be called in if more evidence is needed to clarify an issue.

    The findings

    Once all of the witnesses have been heard the lawyers generally make submissions on behalf of their clients to the coroner. Following the close of submissions the coroner will deliver the findings which will include:

    • The identity of the deceased
    • How the death occurred
    • The cause of the death

    The coroner may also refer the matter to a third party, for example the appropriate disciplinary authority or a state health department.

    Key points to remember when dealing with an inquest:

    • Do not provide a signed statement or enter into detailed conversations with police assisting the coroner without first seeking support and advice from Avant
    • Do contact Avant for support and advice if you receive a summons to attend and give evidence at an inquest
    • Look after yourself through this process – it can be highly stressful. Avant’s personal support program provides support to members who are suffering health issues as a result of a medico-legal claim

      “If the death is reportable or you cannot confidently certify the cause of death you should not sign the death certificate” John Kamaras, Special Counsel, Coronial