reportable and reviewable deaths - deaths which MUST be reported to the Coroner

see also:

• death and the potentially dead
• how to verify death
• how to complete a death certificate for cause of death
• when are doctors required to compulsorily report patients in Australia
• Victorian Coroners Court Website
  • Victorian Coroner's publication - Coroners Process - Information for families and friends (PDF 3.14MB)
• National Coroners' Information System (NCIS)
  • nation-wide centralised database of all coronial deaths since July 2000
• the coronial process - reportable deaths & links to State resources
• Victorian Coroner's newsletter - Coronial Communique
• Vic. coronial process
• The Coroner's Process - Information for Family and Friends (pdf)
• What to Expect When Asked to Identify a Person Who Has Died (pdf)

• investigation of reportable deaths with the objective of reducing the number of preventable deaths and promoting public health and safety.
• it is an independent investigation of reportable deaths to determine:
  • the identity of the deceased person
  • the cause of death
  • in certain cases, the circumstances in which the death occurred
• coroner does not have jurisdiction to investigate a stillbirth¹⁾

• reportable deaths are defined in section 4 of the Coroners Act 2008 and requires²⁾:
  • Victorian Coroner has jurisdiction:
    • the body is in Victoria; or
    • the death occurred in Victoria; or
    • the cause of the death occurred in Victoria; or
    • the person ordinarily resided in Victoria at the time of death
  • AND the death fits one of following criteria:
    • the death was unexpected;
    • the death was violent or unnatural;
      • eg: homicide; suicide; drug, alcohol and poison related deaths;
    • the death resulted, directly or indirectly, from an accident or injury (even if there is a prolonged interval between the incident and death);
      • eg: drownings; deaths caused by a traumatic event such as a motor vehicle accident, or a fall resulting in complications such as a fractured neck of femur or subdural haemorrhage
      • BUT asbestosis itself is NOT reportable
    • the death occurs during a medical procedure or following a medical procedure1 where the death is or may be causally related to the medical procedure and a registered medical practitioner would not, immediately before the procedure was undertaken, have reasonably expected the death and requires BOTH of the following criteria (see Coroner's website for more details on interpretation of these):
      • the death occurs during a medical procedure, or following a medical procedure where the death is or may be causally related to the medical procedure
      • a registered medical practitioner would not, immediately before the procedure was undertaken, have reasonably expected the death
    • a Medical Certificate of Cause of Death has not been signed and is not likely to be signed;
      • eg: where an opinion about the probable cause of death cannot be formed
    • the identity of the person is unknown;
    • the death occurred in custody or care (as defined in the Coroners Act 2008)
      • includes Special Disability Support Accommodation care eg supported residential care accommodation
    • the person was a patient within the meaning of the Mental Health Act 1986; or
    • the death is otherwise specified in section 4 of the Coroners Act 2008
• in addition, the death may be “reviewable” if the person is a child and has lived outside of a hospital (other than for inter-hospital transfers), AND the deceased child is the second or subsequent child of the deceased child's parent to have died.

• a medical practitioner has an obligation to notify the coroner of reportable and reviewable deaths.
• anyone who becomes aware of a reportable or reviewable death must report it to a coroner if they have reasonable grounds to believe that it has not already been reported.
• failure to report is a statutory offence and may incur a fine of 20 penalty units.
• if a person is unsure about whether a death has been reported, they should contact the Coroners Court on 1300 309 519 and ask for the Initial Investigations Office (open 24 hours/7 days a week).
• the usual obligation to maintain confidentiality regarding patient information under the Health Records Act 2001 (Vic) and the Privacy Act 1988 (Cth) does not apply to requests for information by someone acting on behalf of the coroner.

• there is a specific provision for immediate family members to report a death if the deceased person had been discharged from a mental health service within 3 months before their death.

• reportable and reviewable deaths can be reported directly to the Initial Investigations Office of the Coroners Court (Ph 1300 309 519) by the doctor who had been treating the deceased person or who was involved in the management of their care.
  • Victorian coroner online medical deposition form for referring reportable deaths
• In some circumstances (for example, where the death occurred in a hospital), the doctor will be required to complete a Medical Deposition form
• Victorian Coroner now uses an electronic Medical Certificate of Cause of Death (eMCCD) or an electronic Medical Certificate of Cause of Perinatal Death (eMCCPD)
  • step 1: Go to http://www.bdm.vic.gov.au
  • step 2: Click on ‘Secure Login’
  • step 3: Click on ‘Medical Practitioner Online’, Click on ‘eMCCD', Click on ‘Register here’
  • For assistance, contact BDM via bdmdeaths@justice.vic.gov.au

• the body is NOT washed
• clothing is NOT removed
• identification labels (small labels) are attached to the wrist and ankle; the body is wrapped in a body bag and a large identification label is attached to the body bag.
• anything which might be used for forensic purposes should not be removed from the body:
  • intravenous lines (leave cannula in-situ, remove intravenous administration lines and apply intravenous (IV) end-caps).
  • nasogastric tubes (spigot).
  • endotracheal tubes (leave taped in situ).
  • indwelling catheters (disconnect from drainage bag and spigot).
  • other tubing (secure to prevent leakage).
• formal identification of the deceased can take place in the clinical area if family are able to attend the hospital within a reasonable period of time, otherwise identification should take place at the Coroner’s Mortuary.
  • the Hospital Statement of Identification in a Coroner’s Investigation must be completed by the relative/friend identifying the deceased, and witnessed by a Medical Officer.
• as all medical records will go with the body to the Coroner, staff must photocopy the relevant records for that admission and the Coroner's Deposition Form, for hospital use.
• the body is taken to the hospital mortuary for transfer to the city mortuary (exception: where death has occurred in the Emergency Department or the Intensive Care Unit, the Coroner may request to collect the body from there).

• police will attend a hospital (or a scene of death) on behalf of the coroner to obtain details about the deceased, and gather information about the death from health care staff, family, friends and other witnesses.
• the deceased person's full medical record and completed Medical Deposition form normally accompanies the body to the coroner's office for preliminary examination of the body and details.
• the coroner will direct that an autopsy be performed if satisfied that it will assist in the investigation into a person’s death and/or the circumstances surrounding the death. The senior next of kin may write an objection to an autopsy explaining the reasons, this written objection must be made within 48 hours of a coroner ordering that an autopsy be performed.
• the court can facilitate contact with the Donor Tissue Bank of Victoria for families who would like to consider consenting to tissue donation.
• The Victorian Institute of Forensic Medicine (VIFM) manages the Donor Tissue Bank of Victoria. VIFM also undertakes medical procedures required by a coroner for their investigation.
• an inquest may be held if the coroner believes there is some issue of public importance, or he or she needs more information to answer all the questions about the death or fire, or it is mandatory (eg. unknown identity, death in police custody, or homicide). Inquests are only held in a small number of investigations.
• there is no longer an obligation to continue an investigation into a reportable death if the death is due to natural causes and does not occur during or following a medical procedure, is not a reportable death other than being unexpected and is not a reviewable death.