Investigation of deaths
All deaths that are reported to a coroner are investigated (ss 7 (c) & 21(1)). A coroner may also hold an investigation in relation to a missing person, if they have reason to believe that the missing person is dead (as the term ‘death’ also includes suspected deaths). There is no time limit set for the investigation of a death. It is sometimes the case that coroners investigate deaths decades after they occurred, or are suspected to have occurred, as they are not reported to the coroner for many years. Coroners play an active role in investigations, determining which issues are most relevant and deciding how investigations are to proceed. The legislative framework for the investigation of deaths is located in Part 5 of the Act and in Part 2 of the Rules.
The aim of an investigation into a death is to provide the coroner with as much information as possible, to enable the coroner to make the most accurate findings possible. Unlike in a criminal court, the coroner does not punish people or institutions. The coroner does play an important role, however, in ascertaining the cause and circumstances of death. The coroner also makes recommendations, the aim of which is to prevent similar deaths. In this way, the jurisdiction is a positive one, focussed on truth, accountability, transparency, and the health and safety of the public.
The aim of an investigation into a death is to make all the findings set out in s 28(1)(a-e) of the Act:
A coroner investigating a death must find, if possible –
- the identity of the deceased; and
- how death occurred; and
- the cause of death; and
- when and where death occurred; and
- the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1999.
Section 28(2) also states that, where appropriate, the coroner must make comments or recommendations in their findings on any matter aimed at preventing future deaths, matters of public health and safety, or the administration of justice. The coroner uses this power to review safety procedures, responses, training and other factors that may have contributed to or prevented the death.
- One of the coroners’ duties is to correctly identify the deceased person.
- ‘Visual identification’ is carried out by someone who knew the deceased person when they were alive, and who views the deceased person (for more information, refer to ‘A Guide for Families and Friends: Practical matters ’).
- If visual identification is not possible, or requires supplementing, then other procedures may be used to confirm identity such as:
- fingerprinting (which is conducted by police)
- matching features against medical records (such as matching a dental examination and a dental x-ray to dental records, a process which is carried out by forensic odontologists, or matching the serial numbers of implants such as pacemakers)
- DNA testing of close blood relatives, or personal items such as a toothbrush.
If a deceased person is buried and the Chief Magistrate reasonably believes it is necessary for the investigation, they may order that the deceased person be unearthed to be examined by a pathologist. The process of bringing a deceased person out of the ground is called ‘exhumation’. In practice, exhumation is extremely rare.
If a deceased person is to be exhumed, 48 hours’ notice must be given to the senior next of kin and to the owners of the place of burial. The senior next of kin may apply to the Chief Magistrate (and also to the Supreme Court) to prevent the exhumation.
For more information on making an application of this nature, please refer to Key Elements in the Process: Applications.
The investigation file / coronial record
Police attend almost all deaths and assess whether they are reportable. In the case of deaths in medical settings, police may not attend. Once police are notified of a reported death (or attend the scene and ascertain the death is reportable), they will collect statements and evidence to create an initial ‘report to the coroner’. As soon as possible, the deceased person is moved to a mortuary where they are examined.
A trained pathologist (a medical specialist) examines the deceased person carefully and respectfully. The pathologist will use a combination of medical records, scientific tests, scans and physical examination to gather as much evidence for the investigation as possible of how the person died. The Report of Death made to the coroner and other documents that have been added to the investigation file assist them in this task. They will also try to establish if anything may have contributed to the death, made the death more likely, or prevented the death. All the medical examinations are performed with great respect to preserve the dignity of the deceased person.
The pathologist prepares a ‘post mortem report’, which explains the results of any post mortem examinations. In most cases, the coroner will authorise an autopsy and the report will also include the results of the autopsy. An autopsy cannot occur unless it is authorised by a coroner or the Chief Magistrate.
While the deceased person is in the care of the pathologist, they are under the control of the coroner. The coroner has control of the deceased person from the time that a reportable death occurs until they issue a certificate allowing the body to be released for burial or cremation (ss 31 & 32). The coroner must issue the certificate for the disposal of human remains as soon as possible, immediately after the necessary investigations are complete.
In cases where the coroner determines that the death was by natural causes, the police will conduct a limited investigation and the coroner will send a letter to the senior next of kin notifying them that the death was natural and the coroner’s jurisdiction is at an end. This letter can also be sent to other family members who request to be kept informed. This may take several months to occur as a full post mortem report and toxicological testing are still required. The only exception to this is where the identity of the deceased person is unknown, in this case the investigation will continue with the sole goal of establishing identity. An investigation may also end if the coroner becomes satisfied in any other way that a reported death was not actually “reportable” under the legislation (s 3).
For more information on the medical procedures that may be involved in the investigation, please refer to Key Elements in the Process: Investigation of deaths – Post mortem examinations.
The investigating officers continue to add to the evidence, compiling an ‘investigation file’. The investigation file is returned to the coroners’ office once the first round of investigations is complete; this may take several months or more depending on the complexity of the matter.
For more information, refer to Key Elements in the Process: Documents – Investigation file.
An investigation into a death involves gathering information from many sources. Police will gather samples, things and documents from the scene of the death. They will talk to witnesses to the incident or anyone who has information about events leading up to it. All of these statements are written down and then sworn as formal affidavits, and included on the file. In most cases, the coroner will request the deceased’s medical records be included on the investigation file. Once the request is made, the documents become evidence in the investigation. If records are not provided promptly then the coroner may authorise a police officer to seize a copy of the records directly (s 59).
Tasmania Police guidelines stipulate the use of NAATI (National Accreditation Authority for Translators and Interpreters Ltd) accredited / recognised interpreters, if available. If an interpreter is required in any dealings with Tasmania Police, please notify them at the earliest opportunity. It is appropriate for a legal representative to insist on an accredited interpreter for their client. All Tasmanian police officers have completed equity and diversity education and training, and will accommodate the needs of people with disability and people with complex communication needs wherever possible (including the use of a contact advocate and / or support person).
Many organisations can be involved with, or be asked to provide information for, coronial investigations depending on the nature of the death. The most frequently involved are:
- Aged and Community Services Tasmania
- Births, Deaths and Marriages
- Chief Forensic Psychiatrist
- Child Protection Services
- Corrective Services
- Department of Health and Human Services
- Forensic Science Service Tasmania
- hospitals, including:
- Marine and Safety Tasmania
- mortuary ambulance contractors
- Motor Accidents Insurance Board
- residential aged care facilities
- Safe at Home Tasmania
- Tasmanian Health Service
- WorkSafe Tasmania
Depending on the nature of the investigation, some of the other organisations that may be involved include:
- airline companies
- airport operators
- Ambulance Tasmania
- Australian Aged Care Quality Agency
- Australian Defence Force
- Australian Federal Police
- Australian Maritime Safety Authority
- Australian Transport Safety Bureau
- Civil Aviation Safety Authority
- Department of Premier and Cabinet
- Department of Justice
- Director of Public Prosecutions
- Forensic Mental Health Services
- health care professionals
- Mineral Resources Tasmania
- port corporations
- radiation health physicists
- shipping companies
- specialist recovery services
- Tasmania Fire Service
- transport inspectors
- Transport Tasmania
- Unions Tasmania
Here are some examples of how different groups assist coroners in their investigations:
- WorkSafe Tasmania inspectors carry out investigations into workplace deaths in order to:
- discover what may have caused or contributed to the death
- find out whether the workplace was complying with all relevant health and safety laws and regulations
- ensure action is taken to fix any hazards
- provide reports to the coroner.
- They have powers to enter workplaces, examine conditions, conduct tests, and gather statements as well as documentary and physical evidence, to aid them in their functions.
- They also have vital inspection functions to ensure workplaces comply with the law to prevent deaths. In the event of non-compliance inspectors have the power to issue improvement notices, prohibition notices or non-disturbance notices. They can also take direct action in court to seek injunctions and breaches may be prosecuted in a criminal court.
- Transport inspectors are qualified vehicle mechanics who have experience enforcing vehicle standards regulations. They examine motor vehicles to determine a vehicle’s condition; any evidence of mechanical failure and if the vehicle was legally compliant pre-crash. This includes examining all the vehicles systems: brakes, tyres, steering, suspension, safety systems (airbags and seat belts), lights and general vehicle condition. When assisting a coronial investigation, they will provide the coroner with an opinion on the contribution of any defect to the crash.
- Marine and Safety Tasmania (MaST) is the relevant authority for recreational vessels in Tasmania. It oversees domestic commercial vessels, however this role ceases in June 2017. In the case of a maritime incident involving a death, MaST will provide expert advice to Tasmania Police (and through them, to the coroner) on vessel condition, safety equipment and the competency of the operator.
- Australian Maritime Safety Authority (AMSA) takes over responsibility as the relevant authority for domestic commercial vessels in Tasmania from July 2017.
Once the investigating police officer has completed the investigation file, they send it to the coroner. At the coroners’ office the coroners’ associates review the file. They look at the evidence that has been collected and decide if there is any further evidence or extra information that is required. The investigation file provided by police becomes the basis for the coronial record and all further documents obtained are added to it. The coroner oversees this process and may choose to ask for the provision of expert reports or additional statements. A request for more information by the coroner does not necessarily mean that there is anything suspicious about the death. The coroner is required to make the most thorough and accurate findings that they can and so sometimes, they will need more information to do this.
Most organisations involved in the coronial process do not conduct concurrent investigations (investigations into the same death, at the same time) into matters that a coroner is investigating. There are some exceptions to this. For example, whenever there is a death in custody, the Tasmania Prison Service (TPS) conduct an internal review. The Director of Prisons appoints a senior manager to gather information and determine if there are any immediate changes that need to be made. In some circumstances, the Department of Police and Emergency Management will also commission an independent investigation. Copies of all reports that result are made available to the coroner. Hospitals involved in unexpected deaths will often conduct internal investigations and Child Protection Services will always investigate the deaths of children known to the child protection authority (a ‘child death review’).
Coroners’ powers in an investigation
As part of an investigation, the coroner:
- can enter a place and inspect it and anything in it (s 59(1)(a))
- can take a copy of any relevant document (s 59(1)(b))
- can take possession of an article, substance or thing (s 59(1)(c))
- has legal care, custody and control of any article, substance or thing they take possession of (s 59(7))
- can authorise a police officer to do any of the things in s 59 on their behalf
- can restrict access to the place where death occurred (s 34(1)).
Post mortem examinations
The State Forensic Pathologist arranges all post mortem examinations. The State Forensic Pathologist and other qualified pathologists in the Royal Hobart Hospital and Launceston General Hospital conduct the examinations. The term ‘post mortem examinations’ covers all medical investigations of the deceased person, both external and internal. External examinations are not expressly detailed in the Act, which only deals specifically with autopsy (s 36).
The senior next of kin will be consulted about which post mortem examination procedures are to occur. However, the ability to object is only relevant to procedures that are categorised as being a part of the autopsy (see the section below - Autopsy).
In some cases, the cause of death can be satisfactorily determined without conducting an autopsy. In other cases, it may be determined that an autopsy is not likely to provide any additional information as to the cause of death. In these situations, the pathologist will only conduct an external examination of the deceased person. The coroner uses the suite of investigative tools, which are collectively called ‘external examinations’, in consultation with the pathologist to determine the cause of death. These do not involve any invasive procedures.
The standard procedures for an external examination are:
- review of the circumstances of death (including the Report of Death)
- review of the scene of death photographs
- review of medical records (and family history where relevant)
- external visual examination of the deceased person
- taking photographs of the deceased person
- collection of forensic evidence such as fibres, paint, soil, hair and other traces left on the body of the deceased person
- fingerprinting of the deceased person (which is conducted by police after the medical and forensic examinations are complete).
Radiological examinations such as x-rays and CT scans of the deceased person may also occur as a part of the external examinations if the coroner deems them necessary to establish cause of death.
If an autopsy is not required, within 24 hours after the pathologist has completed their examinations, they will provide the coroner with a ‘Provisional Cause of Death’ or ‘interim post mortem report’. Once this occurs, the coroner will sign a certificate authorising the release of the deceased person for burial / cremation. The pathologist will then prepare a formal post mortem report and send it on to the coroner.
An autopsy is a medical procedure that involves a careful examination of the internal parts of the body, which is governed by section 36 of the Act. The aim of any autopsy is to identify the medical cause of death and anything that might have contributed to death; this will often involve searching for signs of illness, injury or disease. Autopsies can provide a lot of information that cannot be gathered in any other way. An autopsy cannot proceed unless a coroner or the Chief Magistrate make an appropriate order. All autopsies are conducted in a respectful and dignified manner.
In Tasmania, the term “autopsy” is used to describe the medical procedure of internally examining the deceased person. Some medical procedures that are not commonly thought of as ‘an autopsy’ are still part of an autopsy under the Act. These procedures will only occur when a coroner or the Chief Magistrate makes an order for an autopsy. These are:
- samples being taken of urine, blood and other fluids for testing
- the taking of tissue samples for testing.
Autopsies in Tasmania are performed by the State Forensic Pathologist with a proportion conducted by other pathologists.
In Tasmania, the term ‘post mortem’ is used in two ways:
- to cover all medical examinations of the deceased person, whether internal or external
- for the report that the pathologist writes after they have completed the examination.
The types of tests that are conducted on samples taken in an autopsy include toxicology (testing for alcohol, drugs, poison and medications), histology / microbiology (testing for disease and infection) and DNA tests.
In most cases of reportable deaths in Tasmania, a full autopsy is ordered. Often, a full autopsy is the only way to satisfactorily determine the cause of death. Reasons for requiring a full autopsy include:
- the circumstances of death: for example, if the death may have been directly or indirectly caused by a deliberate act of another person, it will be very important to have a clear picture of all of the medical evidence
- the likely cause of death: there are some causes of death which can only be accurately determined using an internal examination
- to exclude alternate possible causes of death: in a case where there are multiple possible causes of death, a pathologist will usually be required conduct a full autopsy to identify the actual cause of death
- concerns about medical care: if family members raise concerns about the standard of medical care given to the deceased, the pathologist must ensure that they have a complete picture of the circumstances of death including any surgical procedures conducted or medications administered to the deceased person
- in drug or medication related deaths: in situations involving poisons, illicit drugs or medication, cause of death may not be able to be determined until toxicological tests are completed; a process that may take months - in these cases, without a full autopsy, there is a risk that those tests will come back normal and the cause of death will be unknown.
In almost all cases requiring autopsy, the pathologist will keep small samples of tissue and bodily fluids and send them to Forensic Science Service Tasmania (FSST) for testing. This is to ensure that the deceased person is released for burial or cremation as soon as possible, with no need to wait for the results of tests to come back. In the case of retained samples, the coroner will make an order for the disposal of the sample once the investigation is complete.
In a rare instance, entire organs may be retained. This will only happen if the State Forensic Pathologist believes it is necessary to determine the cause of death or the circumstances surrounding the death. In the case of retained organs, the organ will usually be repatriated with the body before a certificate for release of the body is issued. If this is not possible, the coroner will make a separate release order for the organ / body part and it will be returned or buried in consultation with the senior next of kin.
Coroners have the power to authorise a ‘limited autopsy’. The procedures that are used in a limited autopsy vary according to the circumstances of the case. It may include taking tissue and fluid samples from the deceased person only, or include internal examination of just one part of the body. When there is an objection to autopsy, the wishes of the senior next of kin are taken very seriously. The pathologist will review all the circumstances of the death and make recommendations to the coroner about which medical procedures are absolutely necessary to determine the cause of death. In some cases, the coroner will decide that an autopsy is not necessary, or that a limited autopsy will be sufficient. The coroner has a legal duty to determine the cause of death, so in cases where this cannot be determined without a full autopsy, the coroner will make an order for a full autopsy (s 38(1)).
Within 24 hours of the completion of the autopsy, the pathologist will provide the coroner’s court with a ‘Provisional Cause of Death’ or ‘interim post mortem report’. Once this occurs, the coroner will sign a certificate authorising the release of the deceased person for burial or cremation. The senior next of kin is notified that this has occurred and the mortuary staff will call the funeral director and inform them.
If there is a dispute about who to release the body to, then parties must apply to the Supreme Court under probate law. There is no rule that specifies that the person whom the coroner names senior next of kin has a right to collect the deceased person. Once the coroner makes an order for release, their jurisdiction is at an end.
Once the full post mortem report is prepared (which may take several months), families and close friends may request to have the document sent to a general practitioner (GP) or other medical practitioner of their choice. This allows the document to be discussed with the families / friends by a medical professional who can explain the medical terminology used by pathologists.
Sometimes the cause of death cannot be determined by an autopsy. The coroner may still be able to determine the cause of death once all the evidence in the investigation is considered. The pathologist will always make every effort to make the most accurate report as to cause of death that they are able to on all of the evidence.
Benefits of an autopsy
- An autopsy allows the most accurate findings upon the medical cause of death (often the cause of death cannot be determined at all without a full autopsy).
- An autopsy may assist families by providing the most information possible upon the factors which contributed to or caused the death.
- An autopsy can give families information on genetic illnesses or predispositions, which can be valuable to them in the future.
Objection to autopsy – information for senior next of kin & their representative
If there is an objection by the senior next of kin to an autopsy being performed, please notify the attending police officer or contact the coroner’s court immediately. If you are unable to notify attending police or the coroner’s court (for example, because it is outside business hours and the coroner’s court is not open) you should notify police via the police radio room (131 444). It is very important that the coroner be made aware of the objection as soon as possible, as autopsies are generally carried out as soon as practicable to allow the deceased person to be returned to family quickly (Rule 8(a)).
An affidavit or written objection must be completed and returned to the coroners’ office or Tasmania Police within 24 hours of making a verbal objection (r 6(c)). The affidavit should specify the relationship of the applicant to the deceased person and explain the reasons for the objection. If the coroner receives an objection but decides that a limited or full autopsy is absolutely necessary, they will send out a notice informing the senior next of kin. The senior next of kin is then able to apply to the Supreme Court (within 48 hours of receiving the notice) for an order to prevent this: refer to Key Elements in the Process: Applications.
In rare circumstances, the coroner may proceed immediately to autopsy without the opportunity for the senior next of kin to object. This will only occur if the coroner believes that delay will prejudice the interests of justice.
If you have questions about any of the following procedures, please contact the coroner’s court and / or seek independent legal advice:
- accessing samples taken during an autopsy for use in a paternity test
- collecting sperm from a deceased person for IVF
- collecting ova (eggs) from a deceased person for IVF.
Delays during the investigation
Delays during an investigation can occur for a variety of reasons. Some of these include:
- waiting on the provision of reports such as medical reports, engineering reports, health and safety reports and expert opinions
- delays in receiving toxicology reports, as some medical tests take a long time to prepare and conduct to ensure that the result is accurate
- pressure on court lists, where there are many matters waiting to be heard and coroners must deal with them in turn
- the large volume of work in the coroner’s court generally
- the suspension of the investigation (or the handing down of the findings), which usually occurs if a person is charged with an offence related to the death, fire or explosion (ss 30(3) & 47(4))
- if witnesses are not available (they may have other professional commitments or be overseas), or if Tasmania Police are unable to locate an important witness
- high work load of investigating officers, who have many investigations to conduct at the same time
- annual leave and sick leave taken by investigating officers and court staff.
Delays in the finalisation of coronial matters can cause stress and logistical difficulties. Coroners, coroners’ associates and staff strive to complete all investigations as quickly as possible. If you have any questions about why a particular matter or process is taking so long, please call the coroner’s court. If you represent an interested person, we can provide you with information on what stage the investigation has reached and advise the reasons for any delay.
Will there be an inquest?
There are two situations in which a coroner will hold an inquest into a death after conducting an investigation. The first is where the mandatory inquest provisions of the Act are triggered (s 24(1)); the second is when the coroner considers it desirable to do so (s 24(2)). Any person with a ‘sufficient interest’ in a death can apply to the coroner’s court for an inquest to be held (Act s 27(1) and Rules r 5).
For more information on the inquest process, refer to Key Elements in the Process: Inquests.
For information on applications, refer to Key Elements in the Process: Applications.
Mass Fatality Management
In the tragic event of a mass fatality incident, the Tasmanian Emergency Management Plan comes into effect. This plan details the government response (on the state level) to a wide variety of different types of potential emergencies such as large-scale bush fires and floods. It lists all the different committees and plans in place to prepare for, respond to, and recover from such emergencies.
The Emergency Management Unit oversees and co-ordinates these service on a state level.
As a part of the Tasmanian Emergency Management Plan, the coroner’s court has devised a Mass Fatality Management Plan. This plan lays out what action will be taken by the coroner’s court in the event of a mass fatality incident. It covers areas such as the allocation of responsibilities between departments and the management of incident sites.
Disaster Victim Identification (DVI)
If a mass fatality incident occurs, Tasmania Police utilise the techniques of disaster victim identification to ensure that victims are identified and reunited with their families as soon as possible. Identification procedures such as matching dental records, fingerprints and DNA are used rather than visual identification. Each state in the country has a dedicated Disaster Victim Identification Unit. A coroner will sit on a ‘reconciliation panel’ and oversee the process of identification and repatriation. It may not be possible for any of the deceased persons to be released to their families until the identification process is complete for all deceased persons.
For more information, refer to the Australia New Zealand Policing Advisory Agency web site.