Navigating the next steps in a coronial investigation

What is the Coroners Court – scope of jurisdiction

The Coroners Court is a specialist jurisdiction in Australia which exists to investigate the cause and circumstances of certain specified events, most commonly deaths.

Each Australian State and Territory has its own Coroners Court with unique legislation giving a Coroner powers of investigation. Each version of the Coroners Act defines ‘reportable death’ to determine which deaths must be investigated by a coroner. This varies from state to state.

In South Australia, the definition of a reportable death includes the death of a person who dies as a result of, or within 24 hours of a surgical procedure or the administration of an anaesthetic.

Conversely, the Victorian legislation does not include a time period in its definition but states that a reportable death includes a death which occurs during a medical procedure or following a medical procedure where the death is or may be casually related to the medical procedure.

When might a health practitioner be involved in a Coronial matter?

The most common situation in which a health practitioner can become involved in a coronial investigation will be if the health practitioner was involved in a patient’s care whose subsequent death is being investigated by the Coroner.

A health practitioner may be required to report the death to the Coroner, be asked to provide a copy of their clinical notes to the Coroner or prepare a witness statement and possibly appear to give oral evidence at an Inquest.

What is a reportable death?

Each state and territory’s coronial legislation sets out the legal test for what is a reportable death. If you are unsure whether a death is reportable, you can contact Gilchrist Connell for .

State Legislation

ACT Coroners Act 1997, section 13

NSW Coroners Act 2009, section 6

NT Coroners Act 1993, section 12(1)

QLD Coroners Act 2003, section 8

SA Coroners Act 2003, section 3

TAS Coroners Act 1995, section 3

VIC Coroners Act 2008, section 4

Some initial steps are to ensure that health practitioners clinical notes are in good order and to review them while the matter is still fresh. This will be useful when coming to prepare a witness statement.

Do health practitioners have to comply with a request for a patient’s clinical notes?

Typically, coronial investigations are carried out by police. Health practitioners will usually be contacted by a police officer who has been tasked with gathering evidence to compile a brief for the Coroner to consider.

In some states, the practitioner will receive a formal summons or order issued by the Coroner requiring production of the medical records pertaining to the patient. If such a summons or order is received, health practitioners are required to comply with it and produce the notes.

In other states, the health practitioner may receive a request from the investigating officer to provide the notes without a formal document from the Court. In such a situation, it is important to be clear as to any ethical issues preventing you from providing the notes such as relevant confidentiality obligations which exist after the death of a patient. An example may be where the deceased’s next of kin is not consenting in the context of their not wanting the death to be investigated. However, this may not be sufficient to refuse the investigating officer's request.

Preparing a statement / appearing as a witness

Sometimes a request will be made for the health practitioner to provide a witness statement to explain their assessment and treatment of the patient. This can be requested even if there is no suggestion that the health practitioner’s conduct is being criticised. A Coroner may order a statement be provided.

It is important to obtain legal assistance in preparing a statement for the Coroner to ensure that the statement is drafted clearly and ensures the health practitioners interests protected.

If an inquest is held, a health practitioner may be required to give oral evidence in addition to their written statement. It is important that a health practitioner receives legal assistance to understand the process and receive support in giving evidence before the Coroner.

Ultimately, the Coroner’s role is to investigate the cause and circumstances of a death and if appropriate, make recommendations with the goal of reducing the likelihood of the same circumstances being repeated and avoiding future deaths. Health practitioners play an important role in assisting the Coroner in this task and ideally, ensuring that patient care is maximised in our health care system.